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HEALTH  SCIENCES  STANDARD 


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ORAL  ABSCESSES 


BY 


Kurt  H.  Thoma,  d.m.d. 


LECTURER  ON  ORAL  HISTOLOGY  AND  PATHOLOGY  AND  MEMBER  OF  THE    RESEARCH 
DEPARTMENT  OF  HARVARD  UNIVERSITY  DENTAL  SCHOOL 

INSTRUCTOR  IN  DENTAL  ANATOMY,   HARVARD  MEDICAL  SCHOOL 

ORAL  SURGEON  TO  THE  ROBERT  B.  BRIGHAM  HOSPITAL 

VISITING  DENTAL  SURGEON  TO  THE  LONG  ISLAND  HOSPITAL 

CONSULTING  ORAL  SURGEON  TO  THE   BOSTON   DISPENSARY 


BOSTON 

RITTER    &    COMPANY 

1916 


.,'  ' 


J*r 


The  right  of  reproduction  of  the  original  illustrations  is 
strictly  reserved. 

Copyrighted  at  the  Registry  of  Copyrights,  Washington, 
D.  C,  1916. 

All  Rights  Reserved 


AUTHOR  OF 

ORAL  ANAESTHESIA 


LOCAL  ANAESTHESIA 

IN  THE  ORAL  CAVITY,  FOR  THE 

DIFFERENT  BRANCHES 

OF  DENTISTRY 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/oralabscessesOOthom 


INTRODUCTION 


The  important  discovery  that  septic  lesions  in  the  month 
may  be  foci  or  primary  causes  of  many  acute  or  chronic 
diseases  of  systemic  nature  has  brought  about  great 
changes  in  the  relationship  between  dentistry  and  medi- 
cine. The  teeth,  which  formerly  were  regarded  as  organs 
totally  apart  from  the  rest  of  the  body,  are  now  considered 
as  one  of  the  most  important  gateways  through  which  dis- 
ease may  enter.  The  dentist  who  originally  held  it  his 
duty  mechanically  to  repair  diseased  or  lost  dental  tissue 
is  now  confronted  with  a  problem  the  vitality  of  which, 
if  he  has  a  sincere  interest  in  the  health  of  his  patients 
and  in  the  development  of  his  prof  ession,  demands  a  new 
study  of  the  septic  conditions  of  the  mouth. 

This  book  is  intended  for  the  practicing  dentist  as  well 
as  for  the  student.  It  aims  to  give  a  clear  understanding 
of  the  pathology,  treatment,  and  prevention  of  oral  le- 
sions, and  to  familiarize  the  student  with  the  recognition 
and  nature  of  certain  infectious  diseases  which  may  be 
caused  by  them. 

The  practicing  physician  will  also  find  this  book  of  in- 
terest. In  the  search  for  the  primary  or  secondary  foci 
of  systemic  diseases  he  often  has  occasion  to  look  into 
the  condition  of  the  oral  cavity,  as  it  stands  out  as  an  im- 
portant entrance  for  disease,  although  it  has  been  until 
recently  neglected  as  such. 

This  volume  has  been  written  with  a  view  to  establish- 
ing a  correct  relationship  between  the  condition  of  the 


VI  INTRODUCTION 


oral  cavity  and  the  health  of  the  patient,  and  also  in  the 
hope  that  a  clear  presentation  may  lead  to  a  more  general 
understanding  of  this  new  field. 

The  author  wishes  to  express  his  sincere  thanks  to  those 
of  his  friends  who  have  aided  him  in  bringing  his  book 
before  the  profession.  He  wishes  especially  to  express 
his  indebtedness  to  Dr.  T.  B.  Hartzel  for  his  kind  assis- 
tance in  furnishing  colored  microphotographs  of  lesions 
produced  experimentally  in  the  rabbit ;  to  Dr.  L.  B.  Mor- 
rison, of  the  Robert  B.  Brigham  Hospital,  for  his  compe- 
tent assistance  in  radiography  of  hospital  cases;  to  Dr. 
William  P.  Cooke,  for  furnishing  radiographs;  to  Dr. 
W.  H.  Potter,  for  his  examination  chart;  and  to  Dean 
Eugene  H.  Smith,  of  the  Harvard  Dental  School,  for 
photographs  of  models  of  two  cases  showing  the  results 
of  judicious  extraction  of  decayed  teeth  in  children.  In 
connection  with  the  more  detailed  compilation  of  the 
various  parts  of  this  volume,  the  author  wishes  to  thank 
Miss  Herf ord,  for  her  efficient  work  in  delineation,  and 
Mr.  John  W.  Cooke,  for  his  aid  in  the  preparation  of  the 
manuscript. 

Kurt  H.  Thoma,  d.m.d. 


43  Bay  State  Road, 

Boston,  Massachusetts. 
July  3,  1916. 


CONTENTS 


PAGE 

I.     THE  PHENOMENA  OF  INFECTION 1 

The  Infective  Virus 1 

Bacterial  Ferments 2 

Extracellular  Ferments ;  Intracellular  Ferments ....  2 

Toxins    (extracellular  toxin) 3 

The  Body  Cell 3 

Ferments  of  the  Body  Cell 3 

Phagocytes 4 

Two  Biological  Laws • 4 

Protective  Defences  of  the  Body 4 

Resistance   4 

Decrease  of  Resistance ;  Increase  of  Resistance 4,  5 

Bacterial  Immunity 5 

Natural  Immunity ;  Acquired  Immunity 5 

Toxin  Immunity   6 

The  Process  of  Infection 6 

Incubation    6 

Sensitization 7 

Protein    Poison     (Intracellular    Toxin)     Caused    by 

Bacterial  Destruction 7 

Protein  Poison  Caused  by  Bacterial  Metabolism  from 

the  Body  Cell 8 

The  Action  of  the  Bacterial  Ferments 8 

The  Influence  of  the  Medium 8 

By-products  of  Bacterial  Metabolism 8 

Toxin     9 

Clinical  Picture  of  the  Infection 9 

Influence  of  Quantity  in  Infection 9 

Influence  of  Bacterial  Growth  in  Infection 9 

Influence  of  Virulence  in  Infection 9 

Acute  and  Chronic  Infection 10 


Viii  OEAL   ABSCESSES 


PAGE 

Local  Infection 10 

Local  Effects   10 

General  Effects   10 

Fever ;  Changes  in  the  Blood 10 

Geneeal  Infection   11 

Toxemia    11 

Bacteremia    11 

Metastasis    11 

Secondary  or  Transported  Infections 11 

The  Focus    12 

Channels  of  Absorption 12 

Oral  Foci   13 

Secondary  Manifestation 13 


II.     HISTORY   AND    CLASSIFICATION    OF    ORAL   AB- 
SCESSES         15 

History    15 

Classification    15 


III.  PATHOLOGICAL  DEVELOPMENT  AND  DIAGNOSIS 
OF  ALVEOLAR  ABSCESSES  CAUSED  BY  DIS- 
EASES OF  THE  DENTAL  PULP 18 

Varieties. 

Acute  Periodontitis  and  its  Sequels 18 

Proliferating  Periodontitis  and  its  Sequels 19 

1.   Acute  Periodontitis  and  its  Sequels. 

Definition. 

Varieties. 

Acute   Apical   Periodontitis 19 

Acute  Lateral  Periodontitis 19 

Acute  Interradial  Periodontitis 19 


CONTENTS IX 

PAGE 

Etiology. 

Traumatic  Injury  of  the  Tooth 20 

Infection  from  Adjacent  Teeth .' 20 

Infection  from  Pus  Pockets 20 

Thermal  Shocks 21 

Chemical  Action  of  Fillings 21 

Crowned  Teeth    21 

Decay  of  Deciduous  Teeth 21 

Decay  of  Permanent  Teeth 22 

Filling  Teeth  with  Infected  Pulps 23 

Instrumentation 23 

Change  in  Oxygen  Tension 23 

Course  of  the  Disease. 

Acute  Periodontitis    24 

Acute  Alveolar  Parulis 24 

Subperiosteal  Parulis  24 

Subgingival  Parulis 25 

Sinus  into  Mouth   25 

Sinus  to  the  Face    25 

Sinus  to  the  Antrum  of  Highmore 26 

Sinus  to  the  Nasal  Cavity 26 

Complications. 

Osteomyelitis    26 

Ostitis    26 

Necrosis 26 


Termination. 

Resolution    27 

Scar  Bone    27 

Chronic  Alveolar  Abscess 27 

With  Active  Sinus 27 

With  Closed  Sinus 27 

Subacute  Alveolar  Abscess 28 

Exostosis  of  the  Root 28 

Necrosis  of  the  Root 29 


ORAL   ABSCESSES 


PAGE 

Diagnosis.     (Local    Symptoms,    General    Symptoms, 
Clinical   Signs,  Radiographic   Examination.) 

Acute  Periodontitis 29 

Acute  Alveolar  Abscess 30 

Dento  Alveolar  Parulis 31 

Chronic  Alveolar  Abscess 33 

2.   Proliferating  Periodontitis  and  its  Sequels. 
Definition. 

Varieties. 

Apical  Granuloma 35 

Lateral  Granuloma  35 

Interradial  Granuloma    35 

Etiology. 

Decay  of  the  Tooth 36 

Incomplete  Pulp  Extirpation 36 

Inefficient  Root-canal  Treatment 37 

Inefficient  Root-canal  Filling 38 

Invasion  of  Bacteria 38 

Death  of  Pulp  Without  Access  of  Air 38 

Haematogenous  Infection   39 

Course  of  the  Disease. 

Proliferating  Periodontitis   39 

Granuloma    39 

Subacute  Attacks    40 

Exostosis  of  the  Root 40 

Necrosis  of  the  Root 40 

Termination. 

Resolution     41 

Osteomyelitis    41 

Cysts    41 

Diagnosis.     (Local    Symptoms,    General    Symptoms, 
Clinical  Signs,  Radiographic  Examination.) 

Proliferating  Periodontitis   42 

Granuloma     42 

Subacute  Attacks    43 


CONTENTS  XI 


PAGE 

IV.  PATHOLOGICAL  DEVELOPMENT  AND  DIAGNOSIS 
OF  ALVEOLAE,  ABSCESSES  DUE  TO  OTHER 
CAUSES  THAN  THE  DISEASE  OF  THE  DENTAL 

PULP  45 

I.  Alveolar  Abscesses  Due  to  Diseases  of  the  Gum  45 

Etiology    45 

Course  of  the  Disease 46 

Diagnosis   (Local  and  General  Symptoms,  Clinical 

Signs,   Radiographic   Examination) 47 

II.  Alveolar  Abscess  due  to  Difficult  Eruption, 

Impaction,  and  Unerupted  Teeth 47 

Etiology    47 

Course  of  the  Disease 49 

Diagnosis    (Local    Symptoms,    General    Symptoms, 

Clinical  Signs,  Radiographic   Examination). .  .49,  50 

V.  PATHOLOGICAL  DEVELOPMENT  AND  DIAGNOSIS 
OF  ABSCESSES  OF  THE  TONGUE  AND  SALI- 
VARY GLANDS  AND  DUCTS 51 

I.  Abscesses  of  the  Tongue 51 

1.  The  Simple  Abscess  of  the  Tongue 51 

Etiology    51 

Clinical  Course  of  the  Disease 52 

Diagnosis  (Local  Symptoms,  Clinical  Signs) 52 

2.  The  Phlegmonous  Abscess  of  the  Tongue 52 

Etiology    52 

Clinical  Course  of  the  Disease 52 

Diagnosis  (Local  Symptoms,  General  Symptoms, 

Clinical  Signs)    53 

3.  The  Tubercular  Abscess  of  the  Tongue 53 

Etiology    53 

Clinical  Course  of  the  Disease 54 

Diagnosis  (Local  Symptoms,  General  Symptoms, 

Clinical  Signs)    54 


Xll 


OEAL   ABSCESSES 


PAGE 

II.  Abscesses  of  the  Salivary  Glands  and  Ducts  . .  54 

Etiology    55 

Primary  Infections  55 

Secondary  Infection  55 

Salivary  Calculi    55 

Clinical  Course  of  the  Disease 56 

Diagnosis  (Local  Symptoms,  Clinical  Signs,  Rad- 
iographic Examination)   56,  57 

VI.    BACTERIOLOGY  OF  ORAL  ABSCESSES 58 

Importance  of  Bacteriological  Study 58 

Methods  of  Collecting  Bacterial  Specimens 59 

From  Acute   Abscesses    59 

From  Chronic  Abscesses  and  Granulomata  of  Teeth 

which  are  extracted 59 

From  Chronic  Abscesses  and  Granulomata  in  Apiec- 

tomy    60 

Methods  of  Bacterial  Study 60 

Immediate  Microscopic  Study 60 

Inoculation  of  Artificial  Culture  Media 60 

Inoculation  of  Animals   61 

Review    of    the    Bacteriological    Study    of    Oral 

Abscesses   61 

Schreier,              1893,  on  Parulis   61 

Miller,                 1894,  on  Acute  Alveolar  Abscess. . .  62 

Arkovy,               1898,  on  Chronic  Alveolar  Abscess . .  62 

Goadby,               1903,  on  Acute  Abscess 62 

Partsch,  1904,  on  Zahne    als    Eingangspforte 

fur  Tuberculose 63 

Monier,  1904,  on  Osteo   Periostite    (Alveolar 

Parulis)     63 

Vincent,  1905,  on  Suppuration  Dentaire  sous 

Periostique   65 

Mayerhofer,        1909,  on  Periostitis  Dentalis 65 

Idman,                 1913,  on  Acute  Alveolar  Abscess. .  .66-70 
Gilmer,                1914,  on  Acute    and     Chronic    Ab- 
scesses      70 

Thoma,  1915,  on  Actinomycosis     of     Dental 

Hartzel     and                        Granulomata    70 

Henrici,           1913-14-15,  on  Streptococci  of  Chron- 
ic Oral  Infections 71-75 


CONTENTS  Xlll 


PAGE 

Author's  Remark,  1916   75 

Steinharter,        1916,  on  Staphylococci  causing  Sec- 
ondary Infection 75 

m.     HISTOLOGICAL  PATHOLOGY 77 

Acute  Periodontitis    77 

Acute  Alveolar  Abscess 77 

Dento- Alveolar  Parulis    78 

Chronic  Alveolar  Abscess 78 

Proliferating  Periodontitis   79 

Dental  Granulomata    79 

Simple  Granuloma   79 

Epitheliated  Granuloma    81 

Granuloma  with  Lumen 82 

Cysts    82 

VIII.     SECONDARY  COMPLICATIONS 84 

1.  Involvement  op  Neighboring  Parts 86 

1.  Maxillary  sinusitis    86 

Acute   maxillary  sinusitis 86-88 

Chronic  maxillary  sinusitis 88-92 

2.  Pharyngitis   92 

3.  Trismus    93 

2.  Ophthalmic  Disturbances 94 

1.  Infectious  conjunctivitis  95 

2.  Suppurating  Keratitis 95 

3.  Scleritis    95 

4.  Iritis  96 

5.  Cyclitis    97 

6.  Choroiditis 97 

7.  Retinitis  97 

8.  Intraocular  optic  neuritis 98 

9.  Retrobulbar  optic  neuritis 98 

10.    Glaucoma 99 

3.   Aural  Disturbances 100 

1.  Otitis  media 100 

2.  Otalgia   101 

3.  Reflex  otalgia  101 


XIV  ORAL   ABSCESSES 


PAGE 

4.  Infections  op  the  Lymph  System 102 

1.  Lymphangitis    103 

2.  Lymphadenitis    104-106 

3.  Tubercular  lymphadenitis    106 

5.  Diseases  of  the  Alimentary  Canal 109 

1.  Septic  gastritis  110 

2.  Septic   enteritis 112 

3.  Colitis 113 

4.  Appendicitis    113 

5.  Proctitis   113 

6.  Gastric  and  duodenal  ulcers 113 

6.  Infectious  Diseases  op  the  Blood 115 

1.  Septicemia  116 

2.  Pyemia  117 

3.  Toxemia   118 

Malaise  119 

4.  Anaemia 121 

Pernicious  anaemia 121 

Septic   anaemia 122 

7.  Infectious  Diseases  of  the  Heart 123 

1.  Pericarditis    124 

2.  Myocarditis   125 

3.  Endocarditis  (valvular  and  mural) 125 

8.  Affections  of  the  Nervous  System . . . .  128 

1.  Neuritis    128 

2.  Neuralgia,  trifacial 130 

3.  Chorea    132 

4.  Mental  depression  and  melancholia 133 

9.  Diseases  of  the  Joints 135 

1.  Acute    arthritis 135 

2.  Hypertrophic  arthritis 137 

3.  Gouty  arthritis 137 

4.  Infectious  and  atrophic  arthritis 137-143 

IX.     EXAMINATION  OF  THE  ORAL  CAVITY 144 

Method  op  Oral  Examination  for  the  Physiclvn  ....   145 

1.  Examination  of  the  Soft  Tissues  of  the  Mouth 145 

2.  Examination  of  the  Teeth. 145 

3.  Enlarged  Lymph  Glands 146 


CONTENTS  XV 


PAGE 

Method  op  Oral  Examination  for  the  Dentist 146 

Physical  Examination    146 

1.  General  Health,  of  the  Patient 146 

2.  Diseases  of  the  Soft  Tissues  of  the  Mouth 147 

3.  Diseases  of  the  Teeth 147 

Radiograph  Examination    148 

1.  Obscure  Pain  148 

2.  Diagnosis  of  Condition  of  Devitalized  Teeth ....  148 

3.  Prognosis  before  Root-canal  Treatment 149 

Potter  Case  Charts 149 

Report  Charts  for  Radiologists 149 


X.     TREATMENT  OF  ORAL  ABSCESSES 150 

1.  Treatment  op  Acute  and  Subacute  Conditions  . . .  150 

Removal  of  the  Cause 151 

Rest  of  the  Diseased  Tooth 152 

Application  of  Counter-irritants 152 

Alveolatomy   152 

Incision   152 

Extraction    154 

Systemic    Treatment    (Palliative,    Relief    of   Pain, 

Diet) 155 

Treatment  of  Sinus  to  the  Face 157 

2.  Treatment  op  Chronic  Conditions 157 

Removal  of  Cause 160 

Treatment  with  Antiseptics  placed  into  Root  Canal  160 

Ionic  Medication  161 

Apiectomy    162 

Extraction  and  Curettage 167 

Extirpation  of  Teeth 168 

3.  Treatment  op  Abscesses  Due  to  Diseases  of  the 

Gum  169 

Abscesses  Due  to  Injury  of  the  Gum 169 

Abscesses  Due  to  Pus  Pockets 169 

4.  Treatment  of  Abscesses  Due  to  Difficult  Erup- 

tion, Impaction,  and  Unerupted  Teeth 169 

Extirpation  of  Impacted  and  Unerupted  Teeth. . . .  170 


Xvi  ORAL   ABSCESSES 


PAGE 

5.  Treatment  op  Abscesses  of  the  Tongue  171 

Incision  in  Non-Tubercular  Lesions 171 

Excision  of  Small  Tubercular  Lesions 172 

"Wedge  Excision  of  the  Tongue 172 

Treatment  of  Large  Tubercular  Abscesses  on  the 
Side  of  the  Tongue 173 

6.  Treatment  of  Abscesses  of  the  Salivary  Glands 

and  Ducts  173 

Operation  from  the  Floor  of  the  Mouth 174 

Excision  of  the  Glands 175 

7.  Treatment  of  Systemic  Complications 175 

Surgical  Autoinoculation 176 

Restoration  of  Masticating  Efficienev 177 


XI.     PREVENTION    178 

Prevention   of   Secondary   Disease   from   Oral   Ab- 
scesses      179 

Prevention  of  Periapical  Infection 180 

Radiographic  Diagnosis  Before  Root-canal  Treatment  180 

Anaesthesia  for  Pulp  Extirpation 181 

Complete  Pulp  Extirpation   181 

Cleaning  and  Enlarging  the  Canal 181 

Antiseptic  Medication    182 

Ionic  Medication  184 

Root-canal  Filling 184 

Sterilization  and  Asepsis 185 

Summary  of  Important  Factors  to  Prevent  Periapical 

Infection   186 

Prevention  of  Devitalized  Teeth 186 

Devitalization  for  Sensitive  Dentine  and  Prostheses 

Not  Justifiable  186 

Treatment  of  Hyperemia  and  Exposures  to  Prevent 

Devitalization 187 

Early  Treatment  of  Caries  and  Prophylaxis 188 


XH.  THE  TRUE  VALUE  OF  A  TOOTH 189 


CHAPTER  I 


THE    PHENOMENA    OF    INFECTION 

To  understand  intelligently  and  fully  appreciate  the 
pathology,  bacteriology,  and  treatment  of  oral  abscesses 
and  their  secondary  manifestations  it  is  well  to  study 
first  the  phenomena  of  infection  generally.  The  investi- 
gations made  by  Vaughan  and  Ehrlich  and  others  throw 
new  light  on  many  of  these  questions.  They  solved  prob- 
lems of  greatest  interest  which  formerly  were  only 
vaguely  understood.  For  investigations  on  focal  infec- 
tion we  are  indebted  especially  to  Rosenow  and  Billings. 
It  is  my  privilege  to  use  freely  in  this  chapter  the  state- 
ments of  these  authorities. 

In  all  infectious  processes  there  are  two  principal  fac- 
tors :  the  infective  virus  and  the  body  cell.  Besides  these 
there  is  to  be  considered  the  environment  in  which  the 
infection  takes  place,  the  unorganized  fluids  of  the  body. 

THE    INFECTIVE   VIRUS 

The  infective  virus  may  be  a  particular  protein  and 
physically  different  from  the  medium  in  which  it  exists, 
so  that  its  substance  and  form  can  be  recognized  with  the 
aid  of  the  microscope.  This  we  call  a  microorganism. 
It  may,  on  the  other  hand,  be  a  semi  or  wholly  fluid  pro- 
tein, not  sufficiently  differentiated  from  the  medium  to 
render  it  recognizable  even  with  the  most  delicate  micro- 
scope. Many  such  proteins  pass  through  the  finest 
porcelain  filters  and  cannot  be  deposited  even  by  the  cen- 
trifuge from  the  fluids  in  which  they  exist. 

According  to  Vaughan,  a  living  protein  can  be  solid, 
semi-solid,  gelatinous,  or  liquid,  but  need  not  be  of  a  form 


ORAL  ABSCESSES 


which  our  limited  senses  are  capable  of  recognizing,  even 

when  aided  by  the  most  perfect  lens.  It  is  capable  of 
growth  and  reproduction,  and  in  order  to  do  this  it  must 
assimilate  and  eliminate.  It  can  only  procure  this  nour- 
ishment from  material  which  is  within  its  reach. 

A  bacteria  or  another  infective  virus  is,  therefore,  only 
able  to  live  if  it  can  split  its  surrounding  media  into 
groups  which  fit  into  the  molecular  structure  of  its  cell. 
Therefore  organisms  which  can  make  use  of  the  proteins 
of  the  body  in  which  they  live  are  pathogenic  for  their 
host.  If  they  cannot  make  use  of  the  substances  they 
live  in  they  cannot  cause  an  infection. 

The  agents  in  an  organism  which  prepare 

MENTS  the    f°°d    fOT    aSslmilati0n    are    Called    fer_ 

ferments  ments.  They  are  of  analytic  and  synthetic 
natures.    We  also  speak  of  intracellular  and  extracellular 

ferments. 

Extracellular  Ferments.  Extracellular  ferments  pass 
out  of  the  cell  and  diffuse  more  or  less  widely  through  the 
medium  which  surrounds  it.  They  are  of  analytic  nature, 
rendering  soluble  the  proteins  of  the  medium,  and  the 
complex  molecules  are  broken  down  into  simpler  struc- 
tures, some  of  which  can  be  assimilated,  while  others 
remain  as  protein  poison.  The  activity  of  the  extra- 
cellular ferments  is  easily  affected  by  modifications  in  the 
mediiun  through  which  they  diffuse.  Species  of  animals, 
peculiarities  of  individuals,  slight  changes  of  tempera- 
ture, or  changes  in  the  tissue  cause  variations  in  the 
growth  and  multiplication  of  the  bacteria.  Hence  it  is 
that  one  kind  of  organism  grows  slowly  under  unfavorable 
conditions,  causing  chronic  disease,  while  the  same  bac- 
teria under  favorable  conditions  may  cause  violent  acute 
attacks. 

Intracellular  Ferments.  The  intracellular  ferments 
remain  in  the  cell  in  which  they  are  elaborated  and  are 
in  general  nondiffusible.  They  bear  a  wider  variation 
in  temperature  and  are  not  so  easily  influenced  by  varia- 
tions of  the  composition  of  the  medium  in  which  they 
exist.     While  the  extracellular  ferments  prepare  the  pro- 


THE  PHENOMENA  OF  INFECTION 


teins  so  that  they  can  be  absorbed  by  the  cell,  it  is  left  to 
the  intracellular  ferments  to  construct  the  molecules 
into  the  specific  proteins  which  can  be  assimilated  or 
built  into  the  structure  of  the  cells. 

toy  ins  Extracellular  Toxin.     Besides  these  fer- 

ments which  are  necessary  to  maintain 
life  certain  bacteria  elaborate  another  excretion. 
This  is  a  soluble  extracellular  substance  known  as 
toxin.  It  is  also  probably  a  ferment  or  a  closely  allied 
body.  A  remarkable  characteristic  of  the  toxins  is  that 
they  are  highly  specific  in  their  properties  and  have  the 
power  to  stimulate  the  production  of  antibodies  in  the 
infected  body.  These  antibodies  are  called  antitoxins 
and  are  also  specific.  Antitoxin  of  diphtheria  protects 
only  against  diphtheria  toxin  and  not  against  that  of  any 
other  organism.  The  number  of  bacteria-producing 
toxins,  in  large  quantities  at  any  rate,  is  small ;  the  diph- 
theria and  tetanus  bacilli  are  good  examples  of  toxin- 
producing  bacteria. 

THE    BODY  CELL 

The  cells  of  the  body  also  have  ferments,  as  just  de- 
scribed. There  is  no  living  organism  which  does  not 
produce  its  ferment,  and  all  ferments  are  produced  by 
living  organisms.  The  preparation  of  food  for  assimi- 
lation is  due  to  ferment  action. 

The  ferments  of  the  body  cell  also  work 
op   the  analytically  and  synthetically.    They  are 

BODY    CELL      of  extracellular  and  intracellular  natures. 

Their  primary  function  is  to  supply 
the  cells  which  elaborate  them  with  food.  In 
doing  this  they  also  protect  the  cells  to  which 
they  belong  by  destroying  the  harmful  bodies  both 
particulate  and  formless.  They  are,  however,  of 
a  specific  nature.  While  the  ferments  of  the  body  cells 
of  one  animal  may  digest  one  or  more  bacterial  proteins, 
they  may  be  unable  to  break  down  the  proteins  of  certain 
other  infectious  organisms.  Another  animal,  under  the 
same  general  conditions,  may  resist  the  latter  organism, 


ORAL   ABSCESSES 


but  prove  incapable  of  combating  the  former.  If  they 
are  able  to  break  down  the  bacterial  proteins  these  are 
destroyed  and  the  animal  will  resist  disease. 

Some  cells  not  only  destroy  invading  or- 
^J  ganisms  by  their  extracellular  ferments, 

as  just  described,  but  even  engulf  entire 
bodies  of  bacteria  and  dispose  of  protein  poisons,  digest- 
ing them  by  the  action  of  their  intracellular  ferments. 
Cells  with  such  functions  are  the  wandering  leucocytes, 
lymphocytes,  plasma  cells,  as  well  as  fixed  endothelial 
and  connective  tissue  cells. 

Vaughan*  formulated  the  following  bio- 
TWO  biologi-  logical  laws  which  well  describe  the 
CAL  LAWS         phenomena  of  infection. 

1.  If  the  body  cells  are  permeated  or 
come  in  contact  with  a  foreign  protein  (bacteria),  the 
former  elaborates  a  specific  ferment  by  which  the  latter 
are  destroyed. 

2.  If  the  body  cells  are  attacked  by  destructive  fer- 
ments (toxins),  the  former  form  anti-ferments  (anti- 
toxins) which  have  the  office  of  neutralizing  the  ferments 
to  protect  the  body  cells. 

PROTECTIVE   DEFENCES  OF  THE   BODY 

The  body  cells  of  the  host  attempt  in  the  manner  de- 
scribed to  resist  the  growth  and  multiplication  of  the 
foreign  proteins :  this  growth  constitutes  infection.  The 
resistance  in  an  animal  or  a  person  has 
resistance  ^een  founc[  to  be  greater  at  one  time  and 
diminished  at  another.  In  youth  the  resistance  is  smaller 
than  in  old  age. 

Decrease  of  Resistance.  The  proteolytic  action  of  the 
body  cells,  which  checks  the  progress  of  infection,  can  be 
greatly  decreased  or  removed  by  any  cause  which  lowers 
the  general  or  local  vitality  of  the  tissue.  Among  these 
belong  hunger  and  starvation,  bad  ventilation,  overexer- 
tion, exposure  to  cold,  acute  or  chronic  diseases,  and  focal 
infection.     Local  affections  such  as  injury,  tissue  changes 


*  See  Bibliography. 


THE  PHENOMENA  OF  INFECTION 


from  disease,  the  presence  of  foreign  bodies,  and  the  in- 
terference with  the  circulation  of  the  blood  also  tend  to 
lessen  the  vitality. 

Increase  of  Resistance.  All  conditions  which  are 
favorable  to  the  health  of  the  body  increase  its  resistance 
and  render  the  tissue  cells  more  able  to  overcome  the  in- 
fection. Healthy  food,  beneficial  exercise,  and  good 
circulation,  fresh  air  and  all  prophylactic  means  further 
an  increase  in  the  resisting  power  of  the  body.  The  treat- 
ment of  disease  and  the  careful  search  for  and  surgical 
removal  of  chronic  foci,  from  which  protein  poison  or 
toxins  are  absorbed,  will  also  remove  causes  which  sap 
the  vitality  of  the  individual  and  lower  the  resistance 
against  new  infections. 

RArTF-Riai  Natural  Immunity.  Natural  immunity 
immunity  *s  ^ue  e^ner  ^°  ^ne  ^ac^  ^na^  bacteria  are 

unable  to  feed  upon  the  proteins  of  the 
body  and  therefore  cannot  live,  or  because  they  are  de- 
stroyed by  the  specific  ferment,  formed  as  a  protective 
measure  by  the  body  cells.  There  are  germicidal  agents 
found  dissolved  in  the  plasma  as  well  as  in  the  serum. 
These  are  probably  extracellular  ferments,  while  similar 
agents  are  found  in  these  cells  themselves,  which  are 
probably  intracellular  ferments.  The  first  act  directly 
on  protein  organisms  if  they  are  contained  in  the  plasma 
or  blood  serum ;  the  latter  act  only  after  these  organisms 
have  permeated  into  the  body  cells  which  produce  them. 
Cells  which  have  such  functions  in  a  marked  degree  are 
called  phagocytes. 

Acquired  Immunity.  Immunity  is  acquired  either  by 
disease  or  by  therapeutic  measures. 

Immunity  which  is  due  to  recovery  from  an  infection 
is  the  result  of  the  development  in  the  body,  during  the 
course  of  infection,  of  a  specific  ferment  which  on  renewed 
exposures  immediately  destroys  the  infection. 

Immunity  established  by  vaccination  is  similar  to  that 
induced  by  an  attack  of  the  disease.  A  vaccine  is  the 
same  protein  that  causes  the  disease.     It  is,  however, 


6  ORAL  ABSCESSES 


modified  by  passage  through  animals,  by  growth  at  high 
temperature,  or  by  killing  the  bacteria  by  heat,  so  that 
it  does  not  induce  the  disease  but  yet  it  must  be  so  little 
altered  that  it  will  stimulate  the  body  cells  to  form  a 
specific  ferment  which  will  promptly  on  exposure  destroy 
the  infecting  agent.  This  process  also  is  called  ''protein 
sensitization. ' ' 

toxin  '^'0  understand  toxin  immunity  it  is  neces- 

m m  n  ity  sar7  ^°  nrs^  understand  toxin  activity.  The 
toxin,  which  is  produced  only  by  a  small 
number  of  bacteria,  is  a  soluble  and  diffusible  ferment. 
It  splits  up  the  proteins  of  the  body,  setting  free  the 
protein  poison.  The  body  cells  of  animals  are  stimulated 
by  this  to  produce  an  antitoxin  which  neutralizes  the 
toxin  and  prevents  its  cleavage  action.  The  antitoxin 
does  not  destroy  the  foreign  proteins,  as  do  the  proteolytic 
ferments  of  the  body  cells,  but  only  prevents  the  action 
of  the  elaborated  toxin. 

Antitoxin  for  therapeutic  purposes  can  be  produced  by 
injecting  the  toxin,  gained  by  injecting  a  very  virulent 
culture  in  broth,  into  an  animal,  usually  a  young  horse. 
The  serum  of  the  horse  then  contains  the  antitoxin.  Anti- 
toxin is  rather  a  preventive  than  a  cure.  It  is  much 
more  active  if  given  before  or  in  the  very  beginning  of 
the  infection.  The  inununity  procured  with  serum  con- 
taining antitoxin  is  but  temporary. 

THE    PROCESS   OF   INFECTION 

Pathogenic  proteins  entering  the  body  feed  upon  man's 
proteins,  and  they  convert  the  body  proteins  into  bac- 
n cub ati on  Serial  proteins  by  their  digestive  ferments. 
They  grow  and  multiply  rapidly.  This 
is  essentially  a  process  of  building  up,  as  no  poisonous 
protein  is  liberated  and  the  process  goes  on  without  any 
recognizable  disturbance  in  the  health  of  the  body.  We 
call  this  stage  of  infection  the  period  of  incubation.  Dur- 
ing this  period  the  body  cells  do  not  resist  the  growth 
and  multiplication  of  the  foreign  protein. 


THE  PHENOMENA  OF  INFECTION" 


During  the  period  of  incubation  the  body  cells  are  being 
prepared  for  their  combat  with  the  foreign  proteins. 

From  the  action  of  the  foreign  protein 
TiON  on  the  body  cell  we  note  the  development 

in  the  latter  of  a  specific  proteolytic  fer- 
ment, a  new  function.  This  process  we  call  protein  sen- 
sitization. It  is  a  process  of  distinction  of  the  invading 
organisms.  The  new  ferment  digests  the  invading  pro- 
teins, setting  free  the  protein  poison. 
PROTEIN  {Intracellular  Toxin)  caused  by  bacterial 

poison  destruction.     After  the  body  cells  have 

been  sensitized  the  specific  ferment  which 
is  formed  starts  at  once  to  break  down  the  bacterial  cells. 
This,  however,  does  not  mean  that  the  analytic  process 
of  the  bacteria  is  stopped  at  this  moment ;  on  the  contrary 
the  constructive  action  of  the  bacterial  ferments  con- 
tinues, the  invading  organisms  still  grow  and  multiply 
but  the  process  of  destruction  is  going  on  at  the  same  time. 
A  fight  for  supremacy  ensues  between  the  invading  organ- 
isms by  their  f  ermentive  action  of  bacterial  construction 
and  the  defending  body  cells  by  their  destructive  action 
of  their  newly-formed  proteolytic  ferments.  All  bacteria 
contain  an  intracellular  poison  which  is  a  group  in  the 
protein  molecule  and  is  neutralized  in  most  organisms  by 
combination  with  nonpoisonous  groups.  Therefore  such 
proteins  have  no  action  until  they  undergo  molecular  dis- 
ruption. It  is  the  action  of  the  proteolytic  ferments 
which  splits  the  molecules  of  the  invading  proteins,  set- 
ting free  the  protein  poison  (intracellular  toxin)  which 
makes  the  symptoms  of  the  disease  appear.  Protein 
poison  is  not  a  true  toxin,  although  the  term  toxin  is 
loosely  applied  to  all  poisons  of  infectious  origin.  It  is 
formed  during  all  processes  of  infection,  while  true  toxin, 
as  we  have  already  seen,  is  a  special  ferment  character- 
istic of  certain  bacteria.  Protein  poison  is  produced  by 
destruction  of  the  bacterial  proteins,  is  not  affected  by 
heat  and  does  not  excite  the  formation  of  an  antibody  and 
differs  probably  in  quality  with  the  variety  of  the 
bacteria. 


8  ORAL  ABSCESSES 


Protein  Poison  Caused  by  Bacterial  Metabolism  from 
the  Body  Cells.  It  has  already  been  described  bow  bac- 
teria split  by  their  extracellular  ferments  the  surround- 
ing media  of  their  host.  From  the  newly-formed  struc- 
tures some  are  absorbed  and  others  remain  as  protein 
poison.  The  intracellular  ferments  split  again  into  mole- 
cules which  are  assimilated  and  built  into  the  structure 
of  the  cell,  and  substances  which  are  excreted.  These 
by-products  of  extracellular  and  intracellular  bacterial 
metabolism  may  be  harmless  or  may  be  important  protein 
poisons.  Their  nature  depends  upon  the  special  action 
of  the  ferment  as  well  as  the  quality  of  the  media  of  the 
host  in  which  the  bacteria  grow. 

The  action  of  the  bacterial  ferments.  The  action  of 
the  bacterial  ferments  is  of  greatly  varied  nature.  There 
are  proteolytic  ferments,  hemolysin,  nuclease,  lab- 
ferment,  lipase,  diastatic  ferments,  invertase,  pectase, 
gelase,  oxydase  and  katalase. 

The  Influence  of  the  Medium.  There  is  usually  a  sub- 
stance which  the  bacteria  are  able  to  digest  particularly 
easily,  but  if  this  is  not  present  they  will  attack  harder 
and  less  accessible  material.  The  chemical  make-up  of 
the  medium  naturally  has  a  great  deal  to  do  with  the 
result  and  with  the  by-products  of  bacterial  metabolism. 

By-products  of  Bacterial  Metabolism.  The  by-prod- 
ucts of  the  extra-  and  intracellular  ferment  action  of  the 
bacteria  are  almost  always  relatively  strong  poisons  to 
the  host.  Various  colored  pigments  are  formed  which 
have  not  been  studied  very  much.  From  nitrogenized 
bodies,  or  proteid  substances  which  constitute  the  greater 
proportion  of  animal  tissue,  there  are  formed  complicated 
protein  poisons,  ammonia,  ptomaines,  alkalies,  hydrogen 
sulphid,  aromatics  (Indol,  Skatol,  Phenol,  Tyrosin)  and 
gases  such  as  Nitrogen.  From  carbohydrates  and  animal 
fats  there  are  formed  acids  (lactic  acid,  Formic  acid, 
acetic  acid,  butyric  acid)  and  gases  (carbon  dioxide,  Ni- 
trogen, methane,  Hydrogen). 

This  process  of  bacterial  action  is  a  decomposition,  re- 
sulting in  various  combinations  of  the  by-products  of  the 


THE  PHENOMENA  OF  INFECTION  9 

metabolism.  These  by-products  can  almost  always  be 
recognized  by  the  sense  of  smell  and  it  is  small  wonder 
that  such  substances  if  absorbed  into  the  system  cause 
diseases  of  all  kinds. 

Toxin.  Toxin  is  a  term  which  is  clinically  applied  in  a 
loose  manner  to  any  poisonous  substances  formed  during 
the  process  of  infection.  It  includes  in  this  sense  fer- 
ments, extra-  and  intracellular  toxin,  and  any  protein 
poison  produced  by  the  process  of  bacterial  metabolism. 

In  its  strict  sense  the  term  toxin  is,  as  we  have  already 
seen,  applied  only  to  the  specific  extracellular  bacterial 
poisons,  as  these  alone  cause  the  body  cells  to  produce 
antitoxins. 

CLINICAL   PICTURE    OF  THE   INFECTION 

The  clinical  picture  and  course  of  the  infection  depend 
upon  several  factors. 

Influence  of  Quantity  in  Infection.  The  number  of 
pathogenic  organisms  introduced  into  the  body  plays  a 
great  role.  A  small  number  of  bacteria  may  die,  while 
from  a  large  number  a  certain  amount  is  sure  to  survive 
and  cause  disease. 

Influence  of  Bacterial  Growth  on  Infection.  Bacteria 
differ  as  to  the  rapidity  with  which  they  grow.  This  de- 
pends mostly  upon  the  conditions  they  find;  if  the  body 
proteins  are  easily  digested  they  grow  rapidly  but  if 
they  can  make  use  of  the  proteins  of  their  host  only  with 
difficulty  and  if  the  circumstances  under  which  they  have 
to  grow  are  unfavorable,  as  exclusion  of  oxygen  for 
aerobic  bacteria,  the  growth  and  multiplication  is  slow. 
This  also  has  its  reaction  upon  the  body  cells.  If  the 
infective  virus  multiplies  rapidly,  sensitization  of  the 
body  cells  is  general  and  starts  early.  If  the  infecting 
organism  finds  less  favorable  conditions  for  its  growth  it 
multiplies  slowly  and  the  body  cells  are  sensitized  locally. 

Influence  of  Virulence  in  Infection.  With  bacteria 
whose  virulence  is  great,  disease  will  be  produced  quickly 
by  a  small  number  of  bacteria,  while  a  very  large  number 
is  necessary  if  the  bacteria  is  of  the  low  virulent  type. 


10  ORAL  ABSCESSES 


Acute  and  Chronic  Infection.  If  the  pathogenic  or- 
ganisms enter  the  body  in  large  number,  increase  rapidly, 
or  are  highly  virulent,  and  sensitization  of  the  body  cells 
therefore  is  marked,  starts  early  and  is  general,  the 
developing  disease  is  acute.  If  only  few  organisms  in- 
vade the  body,  or  if  the  infecting  organisms  multiply 
slowly  and  find  unfavorable  conditions,  if  sensitization 
of  the  body  cells  is  mild  and  only  local,  the  disease  takes  a 
chronic  course. 

LOCAL     INFECTION 

If  the  infecting  virus  and  the  sensitization  of  the  body 
cells  is  limited  to  a  certain  part  of  the  body,  we  call  the 
infection  local. 

The  effect  of  the  toxins  (protein  poisons) 
effects  upon  the  body  cells  gives  rise  to  various 
kinds  of  inflammation  such  as  serous,  fibri- 
nous, purulent,  necrotic,  gangrenous  or  proliferative. 
Serous  exudations  into  the  subcutaneous  tissue  follow 
certain  bacterial  infections  in  certain  tissues,  while  the 
same  or  other  bacteria  cause  purulent  inflammation  in 
other  tissues  or  under  other  conditions. 
general  Fever.      Heat   is   produced   during  the 

EFFECTS  processes  of  infection  from  the  following 

sources:  (1)  from  the  unaccustomed 
stimulation  and  consequent  increased  activity  of  the 
cells  which  supply  the  ferments;  (2)  from  the  cleavage 
of  the  foreign  protein;  and  (3)  from  the  reaction  between 
the  proteolytic  ferment  of  the  body  cells  and  the  foreign 
proteins,  especially  if  active  and  virulent  poison  is  lib- 
erated. Fever  must  therefore  be  regarded  as  a  benefi- 
cent process  although  it  often  leads  to  disaster,  especially 
if  the  reaction  takes  place  with  great  rapidity.  The  tem- 
perature is  the  most  delicate  test  of  the  severity  of  the 
inflammation. 

Changes  in  the  Blood.  The  microbian  proteins  almost 
always  produce  an  increase  in  the  number  of  leucocytes 
and  a  decrease  in  the  amount  of  protein.  The  red  blood 
cells  are  sometimes  directly  injured  by  some  of  the  bac- 
terial substances. 


THE  PHENOMENA  OF  INFECTION  11 

GENERAL     INFECTION 

If  the  infective  virus  is  distributed  widely  through  the 
whole  body  and  if  sensitization  of  the  tissue  cells  is  gen- 
eral, we  speak  of  general  infection.  Today  we  know 
that  infections  are  never  entirely  localized  and  that  there 
is  always  absorption  of  bacteria  or  of  the  toxins  formed 
by  the  infectious  process. 

toxemia  ^e  resm^  from  absorption  of  bacterial 

toxins  (either  true  toxins  or  toxins  of 
bacterial  metabolism)  varies  according  to  the  quality  and 
amount  absorbed.  If  the  system  is  flooded  by  large 
amounts,  so  that  there  are  marked  symptoms  of  intoxi- 
cation, we  have  the  picture  of  acute  toxemia.  The 
process,  however,  may  go  on  for  years  without  causing 
gross  symptoms,  and  we  have  a  chronic  toxemia  which 
often  causes  physical  discomfort  and  mental  depression. 
bacteremia  ^e  Dac"teria  are  absorbed  in  quantity 

into  the  blood  and  multiply,  we  have  an 
acute  general  infection  called  septicemia,  which  is  of 
most  severe  character,  resulting  often  in  death. 

Frequently,  however,  we  find  conditions  when  bacteria 
are  not  potent  enough  to  cause  gross  symptoms  of  infec- 
tion, although  they  actually  wear  out  the  cells,  whose  duty 
it  is  to  combat  and  kill  them,  thus  lowering  the  resistance 
of  the  body. 

metastasis  ^e  Presence  °^  bacteria  or  toxins  in  the 
blood  and  tissue  fluid  may  cause  new  in- 
fections or  diseased  conditions  in  other  parts  of  the  body, 
which  are  either  predisposed  by  lowered  resistance  or 
which  have  a  special  affinity  for  the  injurious  agent. 

SECONDARY  OR  TRANSPORTED  INFECTIONS 

Billings  says:  "The  knowledge  of  the  principle  of  sec- 
ondary infection  is  of  importance  for  preventive  as  well 
as  therapeutic  treatment.  The  recognition  and  the  re- 
moval of  the  focus  is  imperative  to  prevent  secondary 
disease  and  is  demanded  as  a  fundamental  principle  to 
stop  the  progression  of  ill-health/' 


12  ORAL  ABSCESSES 


It  has  just  been  shown  that  bacteria  and  toxins  are 
absorbed  from  local  infections  into  the  blood  and  that 
new  infections  occur  at  remote  parts  of  the  body.  This 
is  called  secondary  or  transported  infection,  a  process 
which  has  been  discovered  only  recently  but  which  is  of 
frequent  occurrence. 
the  focus       The  focus  may  be  found  in  any  part  of  the 

body  and  may  be  an  acute  or  chronic  local 
infection.  Foci  are  sometimes  apparent,  but  often  only 
recognized  after  careful  examination  by  the  specialist. 
They  may  be  in  the  nose  and  adjacent  sinuses,  the  oral 
cavity,  the  throat,  the  alimentary  canal,  or  the  genito- 
urinary system. 

channels  of  ^ac^er^a  an(^  their  products  are  absorbed 
absorption    tnr011g]i  two  channels,  the  blood  and  the 

lymph  system.  They  are  carried  into  the 
blood  by  passive  entrance  through  the  stomata  of  the 
capillary  walls,  by  growth  of  the  bacteria  through  walls 
of  the  vessels,  and  by  carriage  into  the  blood  by  leu- 
cocytes. They  also  may  reach  the  blood  by  the  way  of 
the  lymph  vessels  after  their  transmission  through  the 
lymph  glands.  The  deeper  the  infection  is  seated  in  the 
tissue,  and  the  greater  the  pressure  of  the  accumulated 
bacterial  products,  the  larger  is  the  amount  of  absorption. 
Also  the  tissue  in  which  the  infection  occurs  is  of  im- 
portance. Mucous  membrane  absorbs  easily.  An  ab- 
scess enclosed  by  bone  gives  no  chance  for  infiltration  or 
extension;  therefore  the  pressure  is  great  and  the  bac- 
terial products  are  absorbed  readily.  If  there  is  a  sinus 
the  pressure  is  decreased  and  the  amount  of  absorption  is 
diminished.  When  abscesses  or  other  lesions  discharge 
their  exudates  into  the  mouth,  they  reach  different  parts 
of  the  alimentary  canal  where  a  new  focus  may  be  formed, 
especially  if  the  pus  supply  is  long  continued.  But  sec- 
ondary lesions  may  in  turn  also  become  foci  for  further 
and  more  general  infection.  Such  conditions  must  not  be 
mistaken  for  the  primary  cause  of  the  focal  disease,  but 
they  should  be  removed  so  that  they  will  not  serve  to 
further  prolong  and  intensify  the  disease.     (Billings.) 


THE  PHENOMENA  OF  INFECTION"  13 

oral  foci  Oral  foci  may  cause  secondary  infections 
via  the  capillary  or  lymph  system.  Ab- 
sorption is  most  likely  to  be  caused  by  blind,  acute,  or 
chronic  abscesses,  but  occurs  also  from  pyorrhoea  pockets, 
diseased  gums,  and  other  lesions  of  the  mucous  membrane. 
But  infection  may  also  occur  by  pus  discharging  into  the 
oral  cavity,  as  in  pyorrhoea,  and  suppurative  gingivitis 
caused  by  poorly  fitted  crowns  and  bridges,  and  in  alve- 
olar abscesses  with  sinus ;  the  result  then  is  mostly  a  local 
infection  such  as  stomatitis,  pharyngitis,  or  an  infection 
of  the  alimentary  canal,  as  septic  gastritis,  enteritis,  or 
appendicitis.  But  if  the  surface  immimity  of  the  diges- 
tive tract  is  overcome,  the  alimentary  canal  will  become 
a  new  focus,  bacteria  being  absorbed,  causing  further  sec- 
ondary infection. 

Oral  abscesses,  especially  of  the  unsuspected  chronic 
type,  are  in  these  days  of  overdentistried  teeth  a  common 
infection  and  are  of  greatest  importance  in  the  diagnosis 
and  treatment  of  secondary  disease.  The  unsuspecting 
and  deceived  individual  is  usually  not  aware  of  the  men- 
ace which  has  undermined  his  health  or  is  ready  to  cause 
the  most  terrible  chronic  diseases  if  the  conditions  for 
secondary  infections  are  right. 

The  part  of  the  body  affected  and  the  dis- 
SECON D ARY  ease  produced  by  absorbed  toxins  and  bac- 
T!ONSESTA"  teria  depends  upon  several  factors.  The 
different  toxins  have  special  affinities  for 
a  certain  tissue.  The  varieties  of  bacteria  have  prefer- 
ences to  grow  in  certain  tissues  and  even  strains  of  a  cer- 
tain class  of  bacteria  have  a  predilection  of  the  place  in 
which  they  may  accumulate.  Some  forms  of  streptococci 
grow  only  in  conditions  with  abundant  oxygen  supply  (en- 
docarditis), while  others  prefer  places  of  decreased  oxy- 
gen tension  (arthritis).  The  part  of  the  body  in  which 
they  start  a  secondary  infection  is  often  predisposed 
by  traumatic  injury  or  lowered  resistance  from  other 
reasons. 

A  place  which  is  liable  to  become  affected  by  secondary 
disease  may  at  other  times  be  the  seat  of  the  focus,  while 


14  ORAL  ABSCESSES 


lesions  which  usually  are  primary  infections  can  be 
caused  by  transported  or  secondary  infection.  Alveolar 
abscesses  are  almost  always  primary  lesions  whether  they 
are  the  cause  of  secondary  disease  or  not,  but  occasionally 
abscess  formation  starts  on  devitalized  teeth,  with  perfect 
root-canal  fillings  from  haematogenous  infection,  due  to 
diseased  tonsils  or  some  other  focus. 


PLATE      I 


Fig.  1. — Predynastic  Egyptian  Skull  from  Upper  Egypt,  shows  loss 

of  bone  due  to  abscess  condition  on  the  buccal  roots  of  the  upper 

first  molar.     The  pulp  in  this  tooth  was  exposed  from  abrasion. 


Fig.  2. — Oeclusial  view  of  upper  jaw  of  same  skull  showing  abra- 
sion of  the  teeth  and  the  exposed  pulp  chamber  of  the  first  molar. 


PLATE      II 


Fig.  3. — Prehistoric  Peruvian  skull  from  the  cave  Huaricauc.    There 

is  a  great  deal  of  bone  lost  in  the  upper  incisor  region  from  acute 

abscess  condition. 


CHAPTER  II 


HISTORY  AND  VARIETIES  OF  ORAL 
ABSCESSES 

...~~^»»  Abscesses  of  the  teeth  are  known  to  have 
occurred  centuries  ago.  We  find  their  bone 
destructive  processes  both  about  the  jaws  of  ancient  civi- 
lized people  such  as  the  Egyptians,  as  well  as  in  ancient 
native  tribes. 

The  older  literature  knows  only  the  alveolar  abscess 
with  acute  symptoms  of  calor,  dolor,  rudor,  and  tumor, 
while  the  discharge  of  pus  from  sinuses  on  the  gum  which 
gave  the  patient  no  discomfort  was  an  obscure  quantity 
neglected  by  the  dentist  who  then  considered  it  his  duty 
only  to  relieve  pain  and  plug  cavities.  Later  this  con- 
dition was  considered  the  termination  of  the  acute  alve- 
olar abscess  which  did  not  yield  to  treatment.  It  was 
called  chronic  alveolar  abscess. 

Abscess  sacks  found  adhering  to  extracted  roots  or 
teeth  furthered  the  knowledge  of  the  pathology  of  the 
dental  abscesses,  and  in  cases  where  neither  the  gum  nor 
the  tooth  showed  any  sign  of  suppurating  condition,  the 
term  " blind  abscess"  was  applied.  The  blind  abscess 
usually  gave  no  apparent  discomfort  and  therefore  was 
classified  with  the  chonic  abscess.  At  that  time,  teeth 
with  diseased  pulps  were  either  neglected  by  the  patient, 
or  if  treatment  and  relief  of  pain  was  sought,  extracted. 
But  when  the  value  of  the  teeth  for  mastication  became 
better  understood,  men  set  out  to  preach  the  saving  of 
teeth,  and  methods  were  invented  to  treat  the  pulpless 
teeth.  I  do  not  believe  that  the  fathers  of  conservative 
dentistry  meant  to  convey  the  meaning  of  the  doctrine 
which  became  popular.    It  is  not  reasonable  to  try  to 


16  OKAL  ABSCESSES 


save  every  tooth,  no  matter  how  diseased  it  is  and  how 
inaccessible  the  root-canals  may  be.  But  it  was  expected 
of  every  dentist  that  his  greatest  aim  should  be  to  save 
all  teeth  and  that  it  showed  lack  of  ability  to  be  obliged 
to  sacrifice  a  tooth.  On  account  of  the  difficulty  of  root- 
canal  operations  and  the  obscurity  of  the  achievement, 
the  results  frequently  were  poor,  even  if  careful  technique 
were  employed,  and  miserable  if  carelessly  incompetent. 
Because  recommendation  of  extraction  was  looked  upon 
with  disfavor,  the  many  overdentistried  teeth  with  incom- 
plete root-canal  work  were  left  in  the  mouth.  The  result- 
ing condition  was  apparently  normal.  There  was  no 
discomfort  or  perhaps  only  slight  grumbling  sensations, 
overlooked  by  dentist  and  patient. 

Not  until  the  X-rays  were  applied  for  diagnosis  in 
dentistry  have  we  discovered  the  true  condition  of  such 
teeth,  and  since  the  progressive  dentist  secures  the  ser- 
vices of  the  dental  radiologist,  or  has  an  X-ray  machine  of 
his  own,  we  stand  before  the  grave  fact  that  most  pulpless 
teeth  are  the  cause  of  chronic  inflammatory  processes  in 
the  alveolar  process  of  the  maxillary  and  mandibular 
bone,  which  give  no  trouble  or  only  the  slightest  local 
symptoms,  but  are  the  cause  of  much  ill-health  and  dis- 
ease. 
^,  a «-.«-»■*-. ^«       Oral  abscesses  are  best  divided  into  three 

CLASSIFICA-        -,  -,.  i        ,-1  ,.   t  , 

_.«..  classes    according    to    their    etiological 

factors : 

1.  Alveolar  abscesses  caused  by  diseases  of  the  dental 
pulp. 

2.  Alveolar  abscesses  due  to  other  causes  than  diseases 
of  the  dental  pulp. 

3.  Abscesses  of  the  tongue,  salivary  glands,  and  ducts. 

The  first  class  is  by  far  the  most  important  one ;  it  in- 
cludes acute  alveolar  abscesses  caused  usually  by  acute 
diseases  of  the  pulp  and  the  chronic  alveolar  abscesses 
which  are  so  commonly  found  on  pulpless  teeth.  It  has 
been  estimated  that  these  are  found  in  the  mouth  of  a 
large  percentage  of  the  population  of  the  United  States. 
In  the  Eobert  B.  Brigham  Hospital,  where  the  only 


HISTOEY  AND  CLASSIFICATION  17 

patients  are  those  who  suffer  from  chronic  diseases,  I 
found  such  abscesses  in  eighty-eight  per  cent,  of  the  pa- 
tients examined.  The  second  class  includes  abscesses 
caused  by  pyorrhoea,  infection  of  the  gums,  and  impacted 
and  unerupted  teeth.  These  are  by  far  less  frequent 
than  the  previous  group. 

In  the  third  class  we  have  conditions  which  are  of 
rather  rare  occurrence  and  are  frequently  secondary  to 
diseases  of  the  teeth.  However,  abscesses  may  occur  on 
the  tongue  and  in  the  salivary  glands  and  in  ducts,  which 
are  due  to  various  other  causes. 


CHAPTER  III 


PATHOLOGICAL   DEVELOPMENT   OF   ALVE- 
OLAR ABSCESSES  CAUSED  BY  DIS- 
EASES OF  THE  DENTAL  PULP 

varieties  Generally  alveolar  abscesses  due  to  dis- 
eases of  the  pulp  have  been  divided  into 
two  classes:  the  acute  and  the  chronic  condition.  This 
division  is  selected,  according  to  the  large  or  small  amount 
of  discomfort  the  patient  experiences,  that  is,  according 
to  the  symptoms,  without  considering  either  the  etiology, 
the  histopathological  picture,  or  the  termination  of  the 
disease.  We  know  that  the  acute  alveolar  abscess  if  not 
cured  will  terminate  in  the  chronic  form,  but  some  of  the 
so-called  " chronic"  forms  occur  without  passing  through 
the  acute  stage.  As  a  matter  of  fact,  since  only  a  very 
small  percentage  of  chronic  abscesses  have  ever  started 
with  symptoms  of  discomfort,  the  classification  of 
" acute"  and  " chronic"  is  therefore  not  scientifically 
correct.  A  closer  study  of  the  pathological  stages  shows 
that  the  acute  abscess  involves  a  process  of  destruction 
while  the  so-called  chronic  abscess  is  a  process  of  inflam- 
matory new  growth.  This  proliferating  new  growth  is  of 
a  more  or  less  circumscribed  character,  while  the  acute 
condition  of  destruction  is  of  a  diffuse  nature,  spreading 
into  the  adjacent  parts. 

I  shall  therefore  distinguish  two  varieties  of  alveolar 
abscesses  due  to  diseases  of  the  dental  pulp.  Both  repre- 
sent a  progressive  chain  of  pathological  changes,  the  first 
of  a  destructive,  the  second  of  a  constructive,  nature. 

1.  Acute  Periodontitis  and  its  sequels — or  changes  of 
destructive  nature  beginning  with  acute  periodontitis, 


PLATE 


Fig.  4. — Bicuspid  with  apical  abscess.     Incisor  with  lateral  abscess. 
Molar  with  inter-radial  abscess. 


ALVEOLAE  ABSCESSES  19 

culminating  in  acute  alveolar  abscess  or  alveolar  parulis, 
and  ending  in  chronic  alveolar  abscess  and  its  sequels. 
2.  Proliferating  Periodontitis  and  its  sequels — or 
changes  stimulating  inflammatory  new  growth  beginning 
with  proliferating  periodontitis  and  resulting  in  a 
granuloma. 

1.    ACUTE    PERIODONTITIS   AND   ITS   SEQUELS 

definition  Acute  periodontitis  and  its  sequels  are 
changes  which  involve  suppurative  de- 
struction of  the  surrounding  tissues  of  the  tooth,  culmi- 
nating in  a  collection  of  pus  in  or  about  the  alveolar 
processes,  called  alveolar  abscess  or  alveolar  parulis. 

Acute  Apical  Periodontitis.  The  natural  outlet  from 
the  pulp  chamber  is  the  apical  foramen,  or  the  apical 
foramina,  and  therefore  we  find  these  openings  the  most 
common  mouths  of  the  infection,  since  they  are  the  natu- 
ral passages  through  which  infected  matter  may  pass 
from  the  dental  pulp  chamber  into  the  surrounding 
tissues  of  the  apex  of  the  tooth.  .  The  sequel  of  the  acute 
apical  periodontitis  is  the  "  apical  alveolar  abscess." 

Acute  Inter  radial  Periodontitis.  This  is  inflammation 
which  occurs  between  the  roots  of  multirooted  teeth  from 
decay  extending  from  the  diseased  dental  pulp  through 
the  floor  of  the  pulp  chamber.  Infection  by  perforation 
of  the  floor  of  the  pulp  chamber  or  inner  sides  of  the  roots 
with  burr  or  root  canal  instruments  also  gives  rise  to  this 
condition.  Its  sequel  is  the  acute  interradial  alveolar 
abscess. 

Acute  Lateral  Periodontitis.  Perforation  of  and  in- 
fection through  the  lateral  wall  of  a  tooth  by  the  burr  or 
root-canal  instrument  gives  rise  to  inflammation  of  the 
periodontal  membrane,  resulting  in  a  lateral  alveolar 
abscess. 

etiology  ^e  diseases  °f  the  dental  pulp  or  pulp 

chamber  are  responsible  for  the  formation 
of  acute  periodontitis,   which  later   develops  into  the 
acute  alveolar  abscess.     This  condition  is  always  due  to  a 


20  ORAL  ABSCESSES 


large  invasion  of  virulent  pyogenic  bacteria.     The  causes 
of  the  infection  are  the  following : 

Traumatic  Injury  of  a  Tooth.  Injuries  received  by 
falling  or  from  a  blow  result  in  inflammation  of  the  pulp. 
The  tooth  may  be  fractured  in  the  crown,  exposing  the 
pulp  to  outside  influences,  or  fractured  in  the  root,  ex- 
posing it  to  the  irritation  caused  by  the  fractured  seg- 
ments. The  hard  substances  of  the  tooth  are  almost 
always  fractured  if  traumatic  injury  occurs,  but  occa- 
sionally this  does  not  take  place  and  pulpitis  is  then 
caused  by  injury  to  the  tissue  in  the  periapical  regions. 
The  same  condition  occurs  occasionally  from  the  action 
of  orthodontia  appliances,  if  force  has  been  applied  too 
abruptly  or  if  the  teeth  are  moved  too  rapidly.  The  in- 
terference with  the  circulation  of  the  pulp  and  the  lowered 
resistance  of  the  tissue  invite  hematogenous  infection, 
which  results  in  suppuration  of  the  tissues  involved.  In 
this  way  acute  periodontitis  may  result  from  primary  in- 
fection of  the  periapical  region  or  by  means  of  the  pulp 
if  the  injury  occurred  in  the  crown  or  side  of  the  root.  If 
no  therapeutic  measures  interfere,  this  will  develop  into 
an  acute  alveolar  abscess. 

Infection  from  Adjacent  Teeth.  Suppuration  often 
spreads  in  the  cancellous  part  of  the  alveolar  process 
causing  acute  infection  of  the  periodontal  membrane  of 
adjacent  teeth.  If  the  infection  occurs  in  this  manner 
there  is,  however,  less  danger  of  involvement  of  the  pulp 
if  it  is  in  good  condition.  Neighboring  teeth  are  fre- 
quently involved  to  an  extent  which  makes  them  so  loose 
that  their  condition  seems  hopeless,  but  the  pulp  resists 
disease  in  these  cases  for  a  long  period,  and  if  the  cause 
is  removed  in  time,  the  periodontal  membrane,  the  fibres 
of  which  have  a  wonderful  resisting  power  to  destruction, 
returns  to  normal  and  the  tooth  regains  its  firmness  in 
the  jaw.  Occasionally,  however,  especially  if  drainage 
of  the  abscess  is  delayed,  the  pulp  becomes  infected,  re- 
sulting in  violent  suppurating  pulpitis. 

Infections  from  Pus  Pockets.  Pus  pockets  between 
the  gum  and  the  tooth  are  the  result  of  the  destruction 


PLATE      IV 


Fig.  5 


Fig.  6 


Fig.  7 


Fig.  8 


Fig.  9 


Fig.  10 


Fig.  11 


Figs.   5  and  6. — Abscess  caused  by  trauma.     The  tip   of  the  teeth  having  been 

fractured. 

Figs.  7  and  8. — Show  the  treatment  of  the  case  Fig.  5.     The  tooth  was  extracted 

and  replaced  by  a  porcelain  tooth,  the  root  having  been  carved  according  to  the 

X-ray  picture  and  attached  to  the  next  tooth. 

Figs.  9,  10  and  11. — Show  teeth  with  abscesses  which  have  involved  neighboring 

teeth. 


PLATE     V 


Fig.  12 


Fig.  13 


Fig.  14 


Fig.  15 


'/ 


Fig.  16 


Fig.  17 


Fig.  18 


Fig.  19 


Figs.  12  and  13.— Apical  abscesses  due  to  pyorrhea  pockets. 

Figs.  14  and  15. — Abscesses  from  temporary  teeth. 

Figs.  16,  17,  18,  and  19. — Abscesses  due  to  decay  of  permanent  teeth.     In  Figures 

17  and  18  the  decay  has  started  under  the  filling. 


ALVEOLAE  ABSCESSES  21 

of  the  alveolar  process  surrounding  the  tooth  by  pyor- 
rhoea alveolaris  or  of  septic  descending  periodontitis 
caused  by  unclean,  unsanitary,  ill-fitting,  eyiLcrowns  and 
bridges  as  well  as  irritating  fillings.  The  infection  pro- 
gresses towards  the  apex,  and  when  it  reaches  this  part, 
it  destroys  the  blood  supply  of  the  pulp,  producing  septic 
pulpitis  and  apical  alveolar  abscess,  which  usually  dis- 
charges through  the  pocket. 

Thermal  Shocks  Conducted  to  the  Pulp  by  Large 
Metal  Fillings  cause  hyperemia  of  the  pulp,  and  if  the 
irritation  is  strong  enough  and  continued,  it  will  result 
in  pulpitis,  death  of  the  pulp,  and  alveolar  abscess. 

Crowned  Teeth.  Teeth,  fitted  with  entire  porcelain  or 
gold  crowns,  either  for  purposes  of  restoration  of  lost  tis- 
sue or  for  bridge  work,  are  often  believed  to  become 
devitalized  because  contact  with  air  and  with  the  fluids 
of  the  mouth  is  prevented.  It  is  the  author's  opinion 
that  this  is  not  the  real  cause.  The  latest  discovery  in 
dental  histology  teaches  us  that  the  dentin  metabolism 
comes  from  the  dental  pulp,  while  only  the  metabolism 
of  the  adult  enamel  is  dependent  on  the  fluids  of  the 
mouth.  The  metabolism  of  the  dentin  of  a  tooth,  which 
is  covered  entirely  by  a  crown,  is  therefore  not  interfered 
with.  From  practical  experience  we  know  that  a  great 
number  of  teeth  with  well-fitted,  entire  crowns,  stay  in 
perfectly  healthy  condition,  while  the  pulps  of  others 
die.  Two  reasons  can  be  attributed  to  the  death  of  the 
pulp  in  these  cases.  It  may  be  due  to  thermal  shock, 
and  from  the  grinding  which  is  necessary  to  reduce  the 
contour  of  the  tooth.  The  second  reason  is  decay,  which 
has  not  been  entirely  removed,  or,  which  is  caused  by  ill- 
fitting  crowns. 

Decay  of  Deciduous  Teeth.  Deciduous  teeth  are  very 
frequently  neglected  and  their  office  is  very  vaguely 
understood  by  most  of  the  patients.  The  need  of  teeth 
for  the  purpose  of  mastication  is  most  important  in  chil- 
dren because  they  require  more  nourishment  than  the 
adult  to  build  up  their  bodies  and  to  resist  childhood 
illnesses.     These  should  perform  the  function  of  masti- 


22  OBAE   ABSCESSES 


cation  until  the  permanent  teeth  erupt.  Their  other  duty  is 
to  hold  the  space  open  and  prevent  other  teeth  from  mov- 
ing forward  until  the  permanent  teeth  take  their  place, 
in  order  to  prevent  malocclusion.  This  function  which 
concerns  normal  occlusion  of  the  permanent  teeth  is  of 
greatest  importance  and  should  stimulate  us  to  keep  these 
temporary  teeth  in  good  condition  so  as  to  prevent  their 
pulps  from  becoming  diseased.  Acute  abscesses  form 
easily  on  deciduous  teeth  if  the  pulp  has  been  infected  on 
account  of  the  physiological  process  of  bone  absorption 
caused  by  the  eruption  of  their  successors — and  this  in- 
fection is  easily  carried  into  deeper  areas ;  indeed,  fistulas 
to  the  face,  cervical  and  submaxillary  adenitis  caused  by 
temporary  teeth  are  very  frequently  found  in  children. 
If  the  disease  has  progressed  to  the  stage  of  an  acute 
abscess,  the  question  arises  whether  these  teeth  should 
be  extracted  with  malocclusion  as  a  consequence,  or 
whether  they  should  be  retained  with  the  risk  of  infection 
and  its  serious  possibilities  involving  the  development, 
health,  and  even  the  life  of  the  patient. 

Decay  of  the  Permanent  Teeth.  Caries  of  the  dentin 
if  not  stopped  will  progress  in  the  dentinal  tubules  and 
cause  suppurative  pulpitis  before  the  cavity  has  reached 
the  pulp ;  frequently,  however,  the  cavity  extends  directly 
into  the  pulp  chamber.  The  same  process  of  infection 
develops  from  decay  which  has  not  been  entirely  re- 
moved, before  restoring  the  shape  of  the  tooth  by  crown 
or  filling.  The  pulp  may  also  be  infected  during  the 
therapeutic  act  of  excavating  a  cavity.  Even  a  pulp 
exposure  of  minute  size,  almost  always  has  suppurative 
pulpitis  as  a  consequence,  unless  it  receives  the  careful 
treatment  which  is  called  pulp-capping.  This  treatment 
is  advisable  only  in  children's  teeth,  when  the  root  canal 
is  wide  open,  which  prevents  strangulation  during  the 
usually  resulting  period  of  hyperemia  and  mild  inflam- 
mation. In  the  cases  where  the  decay  forms  an  opening 
into  the  pulp  chamber,  the  disease  very  seldom  affects 
the  periapical  tissue.  The  exudates  escape  through  this 
outlet,  and  after  the  stage  of  inflammation,  the  pulp  tis- 


ALVEOLAE  ABSCESSES  23 

sue  degenerates  and  frequently  becomes  hypertrophied, 
which  is  a  measure  of  protection.  But  if  suppuration 
occurs  in  a  tooth  with  a  filling,  or  where  the  natural  open- 
ing becomes  stopped  up  by  food  or  other  substances,  the 
infectious  matter  is  forced  through  the  apical  foramen 
and  forms  an  acute  alveolar  abscess. 

Filling  of  Teeth  with  Infected  Pulps.  A  tooth  with  an 
open  root  canal  and  a  pulp  or  part  of  a  pulp  in  acute  in- 
flammatory condition  should  not  be  sealed  up  after  the 
first  treatment  has  been  applied,  because  in  doing  so  we 
would  close  the  natural  outlet  through  which  the  products 
of  fermentation  and  suppuration  make  their  escape ;  these 
products  would  be  forced  through  the  apical  foramen 
and  infect  the  periapical  tissue.  Such  treatment  is  often 
the  result  of  acute  periodontitis  and  acute  alveolar 
abscess. 

Instrumentation.  Instruments  inserted  into  septic 
root  canals  and  root-canal  instruments  used  for  cleaning 
of  septic  root  canals  act  often  as  plungers  forcing  septic 
material  through  the  apical  foramen  into  the  periapical 
tissue,  inoculating  directly  the  periodontal  membrane  and 
the  bone.  Such  instruments  should  therefore  not  be  used 
until  the  bacteria  have  been  destroyed  by  antiseptic  drugs. 
Perforation  of  the  floor  of  the  pulp  chamber  in  multi- 
rooted teeth  or  piercing  of  the  sides  of  a  root  with  a  root- 
canal  instrument  may  also  be  the  cause  of  acute  periodon- 
titis and  acute  abscess. 

Change  in  Oxygen  Tension.  Very  often  a  tooth  with  a 
diseased  pulp  is  in  a  quiescent  condition  until  the  pulp 
chamber  is  opened  in  order  to  gain  access  for  treatment. 
The  patient  will  return  the  next  day  with  all  symptoms 
of  an  acute  periodontitis,  having  suffered  a  great  deal  of 
pain  during  the  night.  This  is  due  to  a  change  in  oxy- 
gen tension,  and  the  bacteria  which  developed  only  slowly 
because  of  lack  of  oxygen  now  become  extremely  active 
on  account  of  the  access  of  air,  causing  suppuration 
which  will  progress  through  the  apical  foramen  if  the 
tooth  is  sealed  hermetically  after  the  operation. 


24  ORAL  ABSCESSES 


Acute    Periodontitis.      If    bacteria    or 

THE  DISEASE 


products  of  suppuration  escape  through 
the  apical  foramen,  the  periodontal 
membrane  is  first  attacked,  causing  acute  apical 
periodontitis.  The  swelling  of  the  blood  vessels 
and  the  serous  infiltration  enlarges  the  perio- 
dontal membrane  and  pushes  the  tooth  for  a  short 
distance  out  of  the  socket.  This  stage  of  hyperemia 
is  of  short  duration.  Small  particles  of  pus  collect 
near  the  apical  foramen  and  soon  spread  between  the 
fibres  of  the  periodontal  membrane,  which  finally  becomes 
dissolved.  A  tooth  extracted  at  this  stage  shows,  if  the 
periodontal  membrane  adheres  to  the  cementum,  a  red 
appearance  in  the  apical  region.  The  apical  periodon- 
titis may  spread  over  the  whole  surface  of  the  root  and  is 
then  called  acute  total  periodontitis. 

Acute  Alveolar  Abscess.  The  inflammation  now  in- 
volves the  linea  dura,  the  compact  layer  of  bone  lining  the 
alveolar  socket.  The  bone  is  destroyed  as  suppuration 
progresses  and  the  cavity  formed  fills  with  pus.  This 
condition  is  called  acute  alveolar  abscess. 

Alveolar  Parulis.  The  pus  which  stands  more  or  less 
under  pressure  proceeds  in  the  cancellous  part  of  the  bone 
and  finds  its  way  through  some  Haversian  canals,  pene- 
trating the  plate  or  dense  cortical  layer  surrounding  the 
bone.  This  stage  is  sometimes  reached  in  a  short  time,  as 
quickly  as  overnight,  but  at  other  times,  especially  in  the 
mandible,  it  takes  four  to  five  days  for  the  pus  to  burrow 
to  the  surface. 

Subperiosteal  Parulis.  The  Haversian  canals  are  en- 
larged and  show  in  dissected  skulls  as  small  perforations 
through  which  the  pus  escapes  between  the  bone  and 
periosteum.  The  periosteum,  like  the  periodontal  mem- 
brane, is  tough  and  has  a  considerable  resisting  quality 
to  destruction.  The  pus  therefore  spreads  under  the 
periosteum  and  often  accumulates  in  large  quantity, 
sometimes  causing  a  widely  distributed  oedematic  swel- 
ling of  the  face. 


PLATE      VI 


Fig.  20 


Fig.  21 


Fig.  22 


Fig.  23 


Fig.  20. — Acute  periodontitis. 

Fig.  21. — Acute  abscess. 

Fig.   22. — Subperiostial   parulis. 

Fig.  23. — Sub-gingival  parulis. 


PL  ATE     VII 


fcV Mi! 


Spit 


Pig.  24 


Pig.  25 


Fig.  26 


Fig.  27 


Fig.  28 


Fig.  29 


Fig.  30 


Fig.  31 


Fig.  24. — Sinus  to  the  gum. 

Fig.  25. — Sinus  to  the  palate. 

Fig.  26. — Sinus  into  the  antrum. 

Fig.   27. — Sinus  into  the  nasal  cavity. 

Fig.  28. — Sinus  to  the  cheek. 

Fig.  29. — Sinus  to  the  gum  of  the  lower  jaw. 

Fig.  30. — Sinus  to  the  skin  of  the  lower  jaw  progressing  along  the  outside  of 

the  bone.. 
Fig.  31. — Sinus  to  the  chin. 


ALVEOLAE  ABSCESSES  25 

Subgingival  Parulis.  If  the  pus  penetrates  the  perios- 
teum and  collects  under  the  gum  we  speak  of  a  subgingival 
parulis.  This  stage  is  usually  reached  quickly,  but,  in 
other  cases,  only  after  the  subperiosteal  parulis  has  lasted 
for  a  long  time.  The  rate  depends  on  the  resistance  of 
the  periosteum.  The  swelling  caused  by  the  subgingival 
parulis  is  more  rounded,  while  the  tumor  of  the  subperios- 
teal parulis  is  flat. 

Sinus  from  Acute  Alveolar  Abscess  into  the  Mouth. 
If  the  pressure  of  the  pus  at  this  stage  is  not  relieved  by 
surgical  interference,  the  parulis  will  come  to  a  point  and 
break  through  the  gum,  usually  opposite  the  apex  of  the 
root.  This  passage  is  called  a  sinus.  The  course  of  the 
pus,  however,  is  not  always  so  direct.  If  the  periosteum 
is  very  resistant  and  if  the  pus  accumulates  in  large  quan- 
tity, it  may  follow  the  laws  of  gravity  and  least  resistance 
and  pierce  the  periosteum  at  a  place  quite  remote  from  its 
source.  Sinuses  occur  almost  always  at  the  buccal  or 
labial  part  of  the  gum ;  palatal  sinuses  are  more  rare  and 
usually  are  derived  from  the  superior  incisor  teeth  and 
often  lead  some  distance  back  into  the  mouth.  Sinuses 
are  still  more  rare  at  the  lingual  gum  of  the  lower  teeth, 
from  which  point  the  pus  usually  sinks  downwards,  in- 
volving the  tissues  of  the  floor  of  the  mouth. 

Sinus  from  Acute  Alveolar  Abscess  to  the  Face.  If  the 
pus  does  not  readily  find  an  outlet  through  the  gum,  it 
passes  along  fascias  and  muscles  through  submucous  and 
subcutaneous  tissue  until  it  reaches  the  skin  of  the  face. 
Here  it  collects  in  a  similar  way,  as  under  the  gum.  It 
causes  a  swelling  and  extends  the  skin  to  its  limit  before 
it  penetrates  to  the  surface.  (Fig.  30.)  The  course  of  the 
sinus  is  often  a  long  and  tortuous  one.  Sinuses  to  the  skin 
occur  especially  from  severe  subperiosteal  parulis  and 
are  often  caused  by  ignorant  application  of  heat  or  poul- 
tices to  the  outside  of  the  face  to  relieve  the  pain.  Sinus 
to  the  face  from  the  upper  jaw  is  not  very  common.  If 
it  occurs,  the  outlet  usually  is  near  the  malar  process,  as 
seen  in  Pig.  28.  In  the  lower  jaw  the  pus  settles  more  fre- 
quently into  the  tissue,  breaking  below  the  lower  border 


26  ORAL   ABSCESSES 


of  the  mandible.  The  pus  has  been  found  to  follow  the 
course  of  muscles,  finally  finding  an  outlet  on  the  neck  or 
chest.  From  the  inside  of  the  mouth  and  from  the  front 
teeth  the  sinus,  if  it  does  not  find  any  outlet  to  the  gum, 
leads  almost  always  to  the  chin. 

Sinus  for  Acute  Alveolar  Abscess  to  the  Antrum  of 
Highmore.  The  roots  of  the  superior  bicuspids  and  mo- 
lars sometimes  extend  into  the  antrum  and  are  covered 
only  by  the  linea  dura  of  the  alveolar  socket.  Acute 
abscesses  of  such  teeth  easily  form  a  sinus  into  the  antrum 
following  the  course  of  least  resistance.  This  condition, 
of  course,  has  acute  inflammation  of  the  antrum  as  its 
sequel. 

Sinus  for  Acute  Alveolar  Abscess  to  the  Nasal  Cavity. 
If  an  abscess  on  a  superior  incisor  does  not  find  relief  by 
piercing  the  periosteum  and  gum,  a  sinus  may  be  formed 
to  the  inferior  meatus  of  the  nose. 

Acute   Osteomyelitis,   or   destruction   of 

tions  ^e  canceH°us  Part  of  the  bone,  occurs 

always  during  the  formation  of  an  acute 
apical  alveolar  abscess.  The  disease  spreads  easily  in  the 
spongiosa  of  the  bone  and  the  neighboring  teeth  are  usu- 
ally affected  and  are  considerably  loosened.  If  radical 
treatment  is  not  undertaken  at  an  early  time,  it  may  ter- 
minate in  pyemia  or  septicemia,  with  fatal  result. 

Ostitis,  or  death  of  the  bone,  cell  by  cell,  may  be  caused 
by  prolonged  subperiosteal  parulis  where  the  pus  finds 
no  escape  and  destroys  the  outer  plate  of  the  bone.  After 
reaching  the  cancellous  part  of  the  bone  it  continues  as 
osteomyelitis,  which  is  not  different  from  the  osteomye- 
litis which  starts  from  within. 

Necrosis,  or  the  death  of  bone  en  masse,  is  also  fre- 
quently the  result  of  the  acute  alveolar  abscess.  Necrosis 
may  start  from  without  by  subperiosteal  parulis  where 
the  blood  supply  from  the  periosteum  is  cut  off  by  the 
pus  which  separates  it  from  the  bone.  It  may  also  start 
from  within  the  bone  by  osteomyelitis,  as  a  result  of  alveo- 
lar abscesses.  It  most  always  attacks  the  facial  wall  of 
the  bone  and  is  not  often  very  extensive.     The  necrosed 


PLATE     VIII 


Fig.  32. — Skull  showing  large  bone  destruction  due  to  abscesses. 


PLATE      IX 


Fig.  33 


Fig.  34 


Fig.  33. — Ostitis  of  the  hard    palate  caused  by  a  tooth. 

Fig.   34. — Osteomyelitis  of  the  mandible  caused  by  an 
abscess   on  the  lower  first  molar.     The  molar  was  ex- 
tracted   before    the    patient    came   under    the    author 's 
observation. 


ALVEOLAR  ABSCESSES  27 

part  detaches  from  the  healthy  bone  by  absorption,  the 
dead  part  being  called  a  sequestrum.  Pus  discharges 
from  a  sequestrum  in  great  amount  until  it  is  removed. 

Resolution.    Return  to  the  normal  will 
TERMINATION  not     occur    without     early    therapeutic 
measures. 

Scar  Bone.  Frequently  we  find  conditions  which  have 
become  chronic  and  in  which  a  certain  amount  of  repair 
has  taken  place,  usually  leaving  but  a  comparatively  small 
area  of  lessened  density  immediately  around  the  apices  of 
the  roots.  This  new  bone  which  fills  in  the  area  de- 
stroyed during  the  stage  of  active  suppuration,  is  very 
much  more  dense  than  normal  bone  and  appears  in  radio- 
graphs as  a  lighter  area  of  denser  structure.  This  is 
called  scar  bone.     (Figure  37.) 

Chronic  Alveolar  Abscess.  After  the  pus  has  forced  a 
sinus  through  the  soft  tissue,  the  swelling  slowly  subsides, 
and  the  flow  of  pus  diminishes,  the  condition  then  passing 
into  the  chronic  stage.  Inflammatory  granulation  tissue 
is  formed  as  an  attempt  of  healing,  which  becomes  en- 
closed by  fibrous  tissue  to  prevent  the  involving  of  larger 
areas. 

Active  Sinus.  The  suppuration,  however,  continues 
and  the  discharge  flows  through  the  original  sinus  or  finds 
a  new  and  shorter  way,  through  the  tissue  which  has  been 
rendered  more  or  less  immune  during  the  stage  of  acute 
inflammation.  The  walls  of  the  sinus  become  fibrous 
forming  an  adhesion  between  the  abscess  cavity  and  the 
gum,  or  if  the  sinus  leads  to  the  face,  between  the  abscess 
cavity  and  the  skin.  The  skin  on  these  places  appears, 
therefore,  fixed  to  the  bone ;  it  is  drawn  towards  the  dis- 
eased root  apex  in  funnel  fashion.  This  depression  har- 
bors the  mouth  of  the  sinus  at  its  deepest  point.  Chronic 
abscesses  discharge  products  of  suppuration  in  large  or 
small  amount  for  months  and  years. 

Closed  Sinus.  The  mouth  of  the  sinus  of  a  chronic  al- 
veolar abscess  sometimes  becomes  closed  during  a  period 
of  inhibition  of  pus  formation.  This  is  especially  apt  to 
occur  if  the  discharge  starts  to  drain  through  another 


28  ORAL  ABSCESSES 


passage,  such  as  is  the  case  if  an  opening  occurs  into  the 
root  canal  when  the  process  of  decay  breaks  down  the 
tooth.  This  not  only  gives  relief  to  the  discharge  from 
the  chronic  abscess,  but  also  relieves  the  primary  source 
of  infection  due  to  the  death  of  the  dental  pulp.  The 
clinical  picture  of  this  condition  is  similar  to  the  one  of 
the  blind  abscess,  with  the  exception  of  a  scar  on  the  gum 
or  upon  the  face,  formed  by  the  closing  of  the  mouth  of 
the  sinus.  This  sort  of  chronic  abscess  without  sinus  is, 
however,  always  a  sequel  to  the  acute  abscess,  while  the 
true  blind  abscess  is  formed  in  an  entirely  different  way, 
as  we  will  see  later. 

Subacute  Alveolar  Abscesses.  The  closing  of  the  sinus 
by  the  process  of  granulation,  during  a  period  when  sup- 
puration is  subdued  or  drained  through  a  cavity  via  the 
root  canal,  is  usually  not  a  stationary  condition.  The 
cavity  may  become  closed  up  by  food  debris,  or  the  in- 
fection may  become  active  again.  This  happens  par- 
ticularly during  a  period  of  lowered  resistance,  as  during 
pregnancy,  when  all  the  effort  of  the  system  is  directed 
to  other  parts.  In  recurring  cases,  this  secondary  proc- 
ess of  suppuration  is  similar  to  the  primary  one.  The 
pus  accumulates  in  the  cancellous  part  of  the  bone,  the 
granulation  tissue  is  destroyed,  the  sinus  is  reopened,  or 
a  new  outlet  is  formed  to  drain  the  discharge.  The  symp- 
toms of  the  inflammation  are,  however,  much  less  acute ; 
oedematic  infiltration  seldom  occurs  because  the  tissue 
has  been  rendered  more  or  less  immune  by  previous  at- 
tacks. A  subacute  attack  usually  quiets  down  after 
a  while  and  the  condition  continues  as  a  chronic  abscess 
with  sinus,  or  the  sinus  may  even  become  closed  again. 
Such  changes  are  liable  to  be  repeated  innumerable  times 
with  irregular  intervals  of  quietude. 

Exostosis  of  the  Root.  The  fibres  of  the  periodontal 
membrane  have  a  great  power  of  resistance  and  usually 
they  escape  destruction  if  there  is  early  and  sufficient 
drainage  of  the  acute  alveolar  abscess.  But  if  a  chronic 
periodontitis  persists  the  cementoblasts  are  stimulated 
by  irritation  from  the  chronic  inflammation  to  deposit 


PLATE      X 


Fig.  35 


Fig.  36 


Fig.  37 


Figs.  35  and  36. — Photographs  of  teeth  showing 
exostosis  of  the  z'oot. 


Fig.  37. — Molar  with  scar  bone. 


PLATE      XI 


Fig.  38 


Fig.  39 


Fig.  38. — Central  incisor  with  acute  abscess  showing  large  bone  destruction. 
Fig.  39. — Photograph  of  sub-gingival  parulis  caused  by  first  bicuspid. 


ALVEOLAE  ABSCESSES  29 

new  cementum  causing  hypercementosis,  which  is  usually 
restricted  to  the  place  of  disease,  namely,  the  apex  of  the 
root.  This  thickening  or  bulging  of  the  root  is  called 
exostosis  and  histologically  shows  an  accumulation  of 
lamellae  of  cementum  containing  an  abundance  of  cement 
corpuscles  and  Haversian  canals. 

Necrosis  of  the  Root.  In  cases  where  the  parulis  has 
been  severe,  and  the  formation  of  a  sinus  retarded,  as  is 
almost  always  the  case  in  prolonged  subperiosteal  parulis, 
we  usually  get  destruction  of  the  apical  part  of  the  perio- 
dontal membrane.  The  cement  of  the  tooth  is  then  ex- 
posed and  the  denuded  area  shows  a  rough  surface  from 
contact  with  pus,  and  if  the  chronic  alveolar  abscess  lasts 
a  long  time  the  root  becomes  discolored,  having  first  a 
greenish,  and  later  an  almost  black  appearance.  Absorp- 
tion of  tooth  substance  takes  place  at  the  apex  which 
shows  a  ragged  appearance  if  the  tooth  is  extracted.  The 
hard  substances  of  the  tooth  have  not  the  power  to  divide 
and  expel  diseased  fragments,  as  in  bone,  but  we  will  have 
to  consider  this  absorption  as  a  process  of  necrosis.  The 
whole  tooth  represents  the  sequestrum,  dead  bone,  cut  off 
entirely  from  the  blood  supply  which  nourished  it,  from 
the  inside  through  the  pulp  and  from  the  outside  through 
the  periodontal  membrane.  In  long  standing  chronic 
conditions,  where  the  whole  periodontal  membrane  has 
been  destroyed,  the  tooth  has  the  true  appearance  of  dead 
tissue,  the  cementum  of  the  whole  root  having  a  greenish 
black  appearance. 

diagnosis  Acute  Periodontitis.  Local  Symptoms: 
If  the  periodontal  membrane  becomes  in- 
fected from  a  septic  pulp,  the  tooth  becomes  very  tender, 
the  beating  of  the  pulse  can  be  felt  by  the  patient,  and 
the  tooth  protrudes  out  of  the  socket.  The  pain  is  felt 
principally  at  night.  Cold  and  hot  food  have  no  influ- 
ence, but  mastication  causes  great  pain  because  the  tooth 
is,  as  the  patient  expresses  it,  too  long. 

Clinical  signs:  The  tooth  which  causes  the  trouble  is 
sensitive  or  even  extremely  painful  on  percussion ;  often 
it  is  also  more  or  less  loose. 


30  ORAL  ABSCESSES 


Radiographic  examination:  The  radiograph  at  this 
stage  of  the  disease  shows  a  dark  shadow  of  the  thickened 
periodontal  membrane. 

Acute  Alveolar  Abscess.  Local  symptoms:  The  stage 
of  acute  periodontitis  is  usually  of  very  short  duration. 
If  relief  does  not  come  at  once  the  pus  will  collect  and 
form  an  acute  abscess.  The  symptoms  seem  similar  to 
the  ones  of  acute  periodontitis.  Pain  is  very  persistent 
and  increases  in  severity ;  it  is  constant,  deep  and  throb- 
bing, sometimes  excruciating.  Hyperemia  of  the  adja- 
cent tissue  sometimes  is  so  marked  as  to  loosen  the  neigh- 
boring teeth.  Oedematic  swelling  of  the  neighboring 
parts  occurs. 

General  symptoms:  There  is  usually  a  marked  rise  in 
temperature ;  fever  up  to  104°  F.  is  not  uncommon.  Chills 
may  precede  the  fever  and  general  malaise  accompanies 
the  disease. 

Clinical  signs:  If  an  alveolar  abscess  has  formed,  the 
neighboring  teeth  usually  become  tender  and  it  is  difficult 
sometimes  to  find  out  which  tooth  has  started  the  trouble. 
As  the  abscess  starts  from  a  diseased  pulp,  we  can  diag- 
nose the  case  by  testing  the  vitality  of  the  pulp.  A 
discolored  tooth  or  a  tooth  with  a  large  filling  should  be 
suspected.  But  to  find  out  definitely  we  can  apply  the  ice 
test ;  vital  teeth  give  a  reaction.  The  galvanic  or  the  high 
frequency  current  can  also  be  used.  The  teeth  are  dried 
and  rendered  isolated  by  putting  a  piece  of  cellu- 
loid or  rubber-dam  between  their  contact  points ;  the  gal- 
vanic current  is  then  applied.  If  the  galvanic  current  is 
used,  one  electrode  is  held  in  the  hand  and  the  other,  sur- 
rounded by  cotton  saturated  with  normal  salt  solution,  is 
applied  first  to  a  healthy  tooth.  The  patient  notes  the 
sensation  the  current  produces  in  the  healthy  tooth.  The 
teeth  that  are  suspected  are  then  examined  in  the  same 
manner  and  if  a  tooth  gives  no  reaction  it  can  be  con- 
cluded that  its  pulp  is  diseased.  If  a  high  frequency 
apparatus  is  at  hand,  we  let  a  small  spark  jump  at  the 
suspected  tooth,  dried  and  isolated  in  the  manner  just 


ALVEOLAE  ABSCESSES  31 


described.  Pain  caused  signifies  that  the  pulp  is 
healthy,  as  a  diseased  pulp  gives  no  such  reaction. 

Radiographic  examination :  Radiographs  usually  show 
distinct  areas  of  lessened  density  where  the  bone  has  been 
destroyed  by  the  process  of  suppuration.  However,  in- 
filtration of  the  cancellous  part  of  the  bone  is  sometimes 
visible  on  account  of  the  fluoroscopic  properties  of  the 
pus.  The  apex  of  the  diseased  tooth  usually  occupies  the 
centre  of  the  area.  In  the  upper  jaw  where  the  apices  are 
close  to  the  surface,  so  that  the  pus  may  easily  find  an  out- 
let and  accumulate  under  the  periosteum  and  gum  without 
destroying  a  large  amount  of  bone,  sometimes,  even  de- 
stroying no  bone  at  all,  we  may  find  no  area  of  lessened 
density  at  all,  the  bone  appearing  perfectly  normal. 

Alveolar  Parulis.  Local  symptoms :  After  the  pus  has 
penetrated  the  bone,  it  accumulates  under  the  periosteum, 
causing  a  flat  swelling.  In  appearance  the  gum  is  highly 
inflamed  and  red,  and  the  pain  becomes  very  intense. 
Great  relief  usually  occurs  as  soon  as  the  pus  penetrates 
the  periosteum,  when  the  high  pressure  is  relieved  and 
the  pus  collects  under  the  gum,  producing  a  ball-like 
swelling.  If  the  abscess  is  on  the  palatal  side,  this  part 
usually  presents  an  enormous  swelling,  while  parulis  oc- 
curring on  the  buccal  and  labial  sides,  which  usually  is  the 
case,  is  accompanied  by  an  extensive  infiltration  of  the 
surrounding  tissue.  The  oedema  sometimes  partly  or 
even  entirely  closes  the  eye  if  the  trouble  is  in  the  upper 
jaw,  while  in  the  lower  jaw,  the  floor  of  the  mouth,  lower 
part  of  the  cheek  and  neck  are  principally  infiltrated. 
The  localization  of  this  oedema  is  characteristic  of  the 
location  of  the  diseased  tooth.  From  a  molar  or  bicuspid 
in  the  upper  jaw  where  the  upper  part  of  the  cheek  is 
involved  the  corner  of  the  mouth  is  drawn  upwards,  while 
the  swelling  from  the  lower  parts  draws  the  mouth  down- 
ward. If  an  abscess  occurs  at  the  front  teeth  the  re- 
spective lip  is  swollen  and  protruding.  The  submaxillary 
and  submental  glands  for  the  front  teeth  are  almost  al- 
ways enlarged.  When  the  pus  is  about  to  come  to  the 
surface  we  note  that  a  yellowish  spot  appears.     This  is 


32  ORAL   ABSCESSES 


called  pointing  of  the  abscess.  The  abscess,  however, 
does  not  always  point  near  the  tooth  that  is  the  principal 
cause.  The  pus  sometimes  travels  under  the  periosteum 
for  quite  a  distance  and  may  penetrate  at  a  convenient 
point  quite  remote  from  the  place  where  it  leaves  the  bone. 
A  sinus  discharging  from  the  mucous  membrane  of  the 
mouth  or  skin  is  not  always  connected  with  and  caused  by 
an  abscessed  tooth.  Impacted  teeth,  sequestra,  diseased 
salivary  or  lacrimal  glands  sometimes  cause  sinuses,  but 
it  is  not  difficult  to  ascertain  the  cause. 

Differential  diagnosis :  The  lesions  which  may  be  mis- 
taken for  parulis  are  those  of  epulis,  gumma  and  cyst. 
A  true  parulis  resulting  from  a  diseased  pulp  may  also  be 
mistaken  for  a  parulis  caused  by  an  impacted,  partially 
or  entirely  unerupted  tooth,  or  by  an  abscess  caused  by 
pyorrhoea  without  involvement  of  the  pulp.  There  is 
usually  little  difficulty  in  making  the  right  diagnosis. 
Benign  epulis  is  of  slow  development  without  any  pain- 
ful symptoms;  sarcoma  in  the  mouth  is  very  modified, 
and  the  only  malignant  epulis  we  have  to  consider  is  car- 
cinoma. Patients  with  carcinoma  usually  have  a 
neglected  mouth,  and  the  bad  condition  of  the  teeth  and 
the  swelling  of  the  glands,  frequently  gives  the  clinical 
picture  of  parulis.  The  generalizing  character  of  the 
carcinoma  and  the  anamnesis  of  the  disease  helps  in  diag- 
nosis, and  in  a  questionable  case  the  histopathological 
picture  of  a  piece  excised  for  examination  will  decisively 
answer  the  question.  Gummata  are  slow  in  growth ;  the 
history  and  manifestations  at  other  parts  as  well  as  the 
Wasserman  test  will  give  the  desired  information.  Cysts 
are  of  slow  growth  and  show  no  symptoms  of  inflamma- 
tion; an  exploratory  puncture  gives  escape  to  a  clear, 
yellowish,  odorless  fluid.  The  diagnosis  of  parulis  by 
impacted,  unerupted  teeth  and  pyorrhoea  will  be  de- 
scribed in  another  place.  That  sinuses  may  also  derive 
from  glands,  necrosed  bone  and  impacted  or  unerupted 
teeth  has  already  been  mentioned,  while  oedema  of  the 
face  also  occurs  from  the  salivary  glands,  if  their  ducts 
are  obstructed  or  if  infection  involves  them. 


ALVEOLAE  ABSCESSES  33 

General  symptoms :  Parulis  formation  is  almost  always 
accompanied  by  general  malaise ;  fever  reaches  its  highest 
mark  during  the  stage  of  subperiosteal  parulis,  and  leu- 
cocytosis  is  very  marked.  The  patient  gets  worn  out 
from  pain  and  loss  of  sleep,  but  as  soon  as  the  pus  finds 
an  outlet,  the  health  improves  rapidly. 

Clinical  signs:  The  same  that  has  been  said  for  acute 
alveolar  abscess  and  acute  periodontitis  is  true  for 
parulis.  In  addition  we  feel  by  digital  examination  a  fluc- 
tuation which  is  especially  marked  in  subgingival  parulis. 
Pressing  upon  the  swelling  increases  the  pain  consider- 
ably. If  the  abscess  points  or  if  a  sinus  has  already  been 
formed,  there  is  little  difficulty  in  making  a  diagnosis. 

Radiographic  Examination:  The  radiograph,  usually 
shows  the  amount  of  bony  destruction  and  is  employed  to 
find  which  tooth  is  the  causative  factor,  but  in  certain 
cases  no  areas  of  decreased  density  are  visible.  This  is 
especially  the  case  when  the  apices  of  the  teeth  are  close 
to  the  outer  surface,  as  in  the  upper  central  incisors.  In 
extreme  cases  where  films  canot  be  put  into  the  mouth  and 
in  cases  with  sinuses  leading  to  the  face,  large  extraoral 
pictures  should  be  taken,  as  the  cause  is  often  far  removed 
from  the  mouth  of  the  sinus. 

Chronic  Alveolar  Abscess.  Local  symptoms:  The  pa- 
tient who  always  remembers  and  presents  a  history  of  the 
acute  process  almost  always  complains  of  subacute 
attacks,  where  the  gum  swells  up  slightly  and  pus  empties 
into  the  mouth,  and  there  is  usually  a  sense  of  pressure 
and  soreness  of  touch  and  lameness  of  the  tooth. 

General  symptoms:  The  submaxillary  and  submental 
lymph  glands  are  usually  slightly  enlarged.  Complica- 
tions such  as  tonsilitis,  pharyngitis,  and  gastric  and  intes- 
tinal infections  may  occur  due  to  pus  which  is  discharged 
into  the  mouth,  but  infectious  arthritis,  endocarditis, 
toxemia,  and  other  diseases  may  also  set  in,  and  these  can 
be  considered  as  general  symptoms  calling  our  attention 
to  the  causative  factor.  These  complications  will  be  con- 
sidered in  a  special  chapter. 


34  ORAL  ABSCESSES 


Clinical  signs:  A  sinus  is  almost  always  found  on  the 
gum,  or  face;  if  it  has  closed,  there  is  a  visible  scar. 
Whether  or  not  we  have  a  healed  condition,  the  extent 
of  the  lesion  can  only  be  ascertained,  if  the  sinus  is  closed, 
by  radiographic  examination. 

Kadiographic  diagnosis:  The  radiograph  reveals  the 
chronic  abscess  by  an  area  of  lessened  density,  it  also 
discloses  if  there  is  exostosis  or  necrosis  of  the  root  apex, 
which  is  an  important  factor  in  the  determination  of  the 
method  of  treatment. 

2.     PROLIFERATING     PERIODONTITIS    AND 
ITS    SEQUELS 

In  the  last  decades,  teeth  have  been  devitalized  for 
several  reasons  without  realizing  the  danger  of  such  pro- 
ceedings. Dentists  knew  only  of  the  mechanical  diffi- 
culties encountered  in  extirpating  pulps  and  filling  of 
root  canals.  The  result  of  imperfect  root-canal  work 
was,  however,  not  known  until  radiography  was  developed 
for  dental  use.  When  the  so-called  areas  of  lessened 
density  were  shown  in  radiographs  at  the  apices  of  devi- 
talized teeth,  little  attention  was  paid  to  them ;  they  were 
considered  a  neglible  quantity  because  the  patient  had 
no  alarming  symptoms  of  disturbance  and  often  not  even 
the  slightest  discomfort,  and  it  was  considered  good  den- 
tistry to  retain  such  teeth  rather  than  lose  an  important 
organ  of  mastication.  But  since  the  pathology  and  bac- 
teriology of  these  symptomless  lesions  has  been  studied 
more  carefully  and  since  the  important  discovery  of  focal 
infection,  we  have  come  to  realize  the  grave  fact  that  such 
septic  conditions  about  the  teeth  may  be  more  dangerous 
than  the  violent  acute  conditions,  principally  on  account 
of  the  fact  that  their  deceiving  nature  undermines  the 
patient's  general  health  and  causes,  if  conditions  are 
right,  secondary  infections  in  other  parts  of  the  body,  the 
nature  of  which  we  shall  study  in  a  special  chapter. 
definition  Proliferating  periodontitis  and  its  sequel, 
the  granuloma,  are  changes  in  which  new 
formation  of  tissue  from  the  periodontal  membrane  is  the 
important  feature;  suppuration  plays  a  secondary  role 


PLATE      XI! 


Fig.  40 


Fig.  41 


Fig.  42 


Fig.  40. — Lateral  granuloma. 

Fig.  41. — Apical  granuloma. 

Fig.  42. — Interradial  granuloma. 


PLATE     XIII 


Fig.  43 


Fig.  44 


Fig.  45 


Fig.  46 


Fig.  41 


Fig.  48 


Fig.  49 


Fig.  50 


Figs.  43,  44  and  45. — Granulomata  caused  by  decay  of  the  tooth.     There  is  free  eonimuxii- 

eation  from  the  root  canal  into  the  mouth. 

Figs.  46,  47  and  48. — Granulomata  caused  by  incomplete  pulp  extirpation. 

Figs.  49  and  50. — Granulomata  due  to  broken  instruments  left  in  root  canal. 


ALVEOLAE  ABSCESSES  35 

and  does  not  involve  the  surrounding  tissues.  It  is 
characteristic  that  the  condition  starts  without  the  pa- 
tient's knowledge  and  without  symptoms  of  inflammation. 
varieties  Apical  Granuloma.  The  most  common 
seat  of  chronic  periodontitis  and  its  sequel 
and  is  the  periapical  region,  at  the  outlet  of  the  root 
canal  from  which  the  disease  starts. 

Lateral  Granuloma.  Sometimes  teeth  have  accessory 
foramina  as  high  as  the  middle  of  the  root.  These  may 
become  a  source  of  trouble  if  the  root  canal  has  to  be 
treated.  Perforations  by  root  canal  instruments  at  the 
side  of  a  root  are,  however,  more  frequently  the  cause  of 
lateral  abscesses. 

Interradial  Granuloma.  The  floor  of  the  pulp  cham- 
ber is  sometimes  penetrated  in  multirooted  teeth  by  burrs 
or  root-canal  instruments,  seldom  by  decay,  causing 
granulomata  or  chronic  abscesses  between  the  roots.  It 
it  almost  impossible  to  treat  these  interradial  abscesses  on 
account  of  anatomical  difficulties. 

etiology  Proliferating  periodontitis  is  primarily 

caused  as  a  protective  reaction  of  the  tis- 
sue against  irritating  excretions  from  the  root  canal,  such 
as  pus  bacteria  and  toxins,  or  against  injudicious  appli- 
cation of  irritating  drugs,  such  as  formaldehyde,  sul- 
phuric acid  and  other  medicaments  used  during  root  canal 
treatment.  Ulrich  believes  that  haematogenous  infection 
is  the  explanation  for  all  apical  abscesses  with  the  prob- 
able exception  of  teeth  which  have  been  capped  following 
caries.  I  fully  believe  that  haematogenous  infection  is 
the  cause  in  certain  cases,  especially  those  of  infection  or 
reinfection  after  medicinal  treatment,  leaving  an  area  of 
lowered  resistance  in  the  periapical  region,  such  as  a  peri- 
odontal membrane  or  a  denuded  or  necrosed  apex ;  but  it 
seems  to  me  very  improbable  that  all  or  even  a  large 
amount  of  the  cases  should  be  due  to  this  cause.  The  histo- 
pathological  picture  speaks  so  plainly  for  an  irritating 
and  infective  source  from  the  root  canal,  the  fact  that  I 
discovered  blind  abscesses  in  persons  in  whom  no  other 
foci  could  be  found  after  careful  search,  and  the  fact  that 
the  streptococcus,  which  is  almost  always  found  in  the 


36  ORAL  ABSCESSES 


dentinal  tubules,  is  also  the  bacteria  which  most  fre- 
quently inhabits  the  granuloma,  seem  to  me  simpler  and 
more  probable  reasons,  especially  where  we  have  such  an 
obvious  source  as  the  root  canal  from  which  infection  may 
be  continued. 

The  microorganisms  which  sooner  or  later  invade  the 
granuloma  are  never  very  large  in  number.  Their  viru- 
lence has  usually  been  decreased  by  unfavorable 
conditions,  such  as  lack  of  oxygen  and  lack  of  nutrition 
where  most  of  the  organic  matter  has  been  removed,  and 
the  blood  supply  is  cut  off.  The  result  is  a  symptomless 
or  chronic  inflammation  walled  off  by  the  fibrous  sack 
enclosing  the  granuloma,  containing  lymphocytes  and 
leucocytes. 

Proliferating  periodontitis  can  be  caused  whether  the 
pulp  chamber  is  open  or  closed  and  results  from  the  fol- 
lowing conditions : 

Decay  of  the  Tooth.  If  caries  has  destroyed  the  enamel 
and  dentin,  so  that  there  is  an  opening  into  the  pulp 
chamber,  the  products  of  decomposition  have  a  chance  to 
escape  into  the  mouth.  This  prevents  them  from  pene- 
trating through  the  apical  foramen  thereby  infecting  the 
deeper  tissues  surrounding  the  root  of  the  tooth.  While 
the  disease  of  the  pulp  progresses  slowly  towards  the 
apex,  protective  measures  are  taken  by  the  surrounding 
tissue  against  the  poisonous  substances  of  fermentation 
and  decomposition.  The  periodontal  membrane  prolif- 
erates and  forms  a  granuloma,  and  harbors  in  its  center 
fluids  of  decomposition  and  absorption. 

Incomplete  Pulp  Extirpation.  The  extirpation  of  the 
dental  pulp  is  an  operation  which  should  not  be  under- 
taken except  after  serious  consideration  of  its  necessity 
and  most  careful  prognostic  study  of  the  case.  Our 
present  knowledge  of  the  alveolar  abscess  should  warn 
us  of  the  possible  consequences  of  such  an  operation  and 
teach  us  to  make  the  greatest  effort  to  save  the  pulp  by 
prophylactic  as  well  as  by  therapeutic  means.  A  tooth 
should  be  radiographed  to  diagnose  if  a  root  is  straight 


ALVEOLAE  ABSCESSES  37 

or  bent  and  to  ascertain  the  size,  length,  direction,  and 
branching  of  the  root  canals.  Some  teeth  are  bent  to 
such  an  extent,  or  their  root  canals  are  so  obstructed  by 
secondary  deposits  of  dentin  or  pulp  stones,  that  we  are 
not  able  to  remove  the  pulp  entirely,  no  matter  how 
skilled  the  operator  and  how  much  time  is  spent.  We 
stand  therefore  before  an  impossible  task.  Among  these 
cases  belong  many  teeth  which  have  moved  forward  dur- 
ing childhood  on  account  of  loss  of  an  anterior  tooth  and 
these  teeth  have  been  moved  for  large  distances  for  ortho- 
dontic purposes.  This  may  result  in  bent  roots.  Most 
of  the  permanent  teeth  erupt  long  before  the  calcification 
of  their  roots  is  finished,  and  if  force  is  applied  at  the 
stage  of  root  formation,  it  will  move  the  calcified  part  and 
bend  the  uncalcified  apical  region. 

If  parts  of  diseased  pulp  are  left  to  remain  in  the  roots, 
in  branches  of  the  root  canal,  apical  part  or  accessory 
foramina,  this  organic  matter  will,  after  the  tooth  has 
been  filled,  stimulate  proliferation  of  the  periodontal 
membrane  and  cause  a  granuloma.  If  a  healthy  tooth  has 
to  be  devitalized  to  give  attachment  to  bridge  work  or  to 
remove  pulp  stones  which  cause  neuralgia,  the  remaining 
pulp  particles  are  often  infected  by  careless  treatment, 
or  by  bacteria  supplied  by  the  blood  stream.  The  con- 
dition then  is  the  same  as  if  the  pulp  had  been  infected 
in  the  first  place. 

Inefficient  Root-canal  Treatment.  Root  canals  which 
have  not  been  sufficiently  treated  previous  to  the  insertion 
of  the  root  filling,  are  liable  to  cause  the  same  result  as 
just  described.  After  all  the  organic  matter  has  been 
removed  by  mechanical  and  chemical  means,  we  must  still 
consider  the  bacteria  which  are  growing  in  the  micro- 
scopic dentinal  tubules  and  the  accessory  apical  foramina. 
These  should  be  destroyed  by  antiseptics  [ionic  treatment 
with  iodine  was  found  specially  helpful  by  the  writer]  or 
they  will  become  the  source  of  infection,  which  is  espe- 
cially favored  by  incomplete  or  poorly  condensed  root 
canal  fillings.     The  same  condition  occurs  if  root  canal 


38  ORAL   ABSCESSES 


instruments  are  broken  and  left  in  the  canals.  They  ob- 
struct the  way  to  the  apical  part  which  is  left  in  a  septic 
and  unfilled  condition. 

Inefficient  Root-canal  Fillings.  A  root-canal  filling 
which  is  perfect  should  seal  the  apical  foramen  hermet- 
ically so  that  no  infection  can  pass  from  the  tooth  into  the 
surrounding  tissues.  Scrupulous  asepsis  is  also  of  great- 
est importance,  not  only  during  root-canal  treatment,  but 
also  during  root-canal  filling.  If  the  filling  leaves  a  space 
at  the  apex  containing  organic  matter,  moisture,  or  air, 
or  if  the  filling  material  is  of  such  a  nature  that  it  shrinks, 
irritates  or  relies  on  antiseptic  properties,  which  wear 
out  with  time,  it  gives  chance  for  bacterial  growth. 

Invasion  of  Bacteria.  It  may  also  be  caused  by  inva- 
sion of  bacteria,  reaching  the  pulp  by  way  of  the  dentinal 
tubules,  which  can  be  easily  entered  if  the  enamel  has 
been  removed.  If  this  is  the  case  several  factors  must 
be  reckoned  with.  Danger  of  infection  is  certain  if  the 
tooth  is  young  and  if  it  must  be  greatly  reduced  to  fit  a 
crown,  because  the  dentinal  tubules  in  this  case  are  larger, 
less  calcified,  and  nearer  the  pulp.  If  these  little  wounds 
(sections  through  the  dentinal  tubules)  are  not  carefully 
protected  during  the  preparation  of  the  tooth  and  during 
the  time  which  elapses  until  the  crown  is  set,  bacteria 
which  abound  in  the  mouth  will  invade  these  dentinal 
tubules,  multiply,  and  progress  even  after  the  crown  has 
been  set,  until  they  reach  the  pulp  and  cause  suppurative 
pulpitis. 

Death  of  Pulp  without  Access  of  Air.  It  is  a  well- 
known  fact  that  the  pulp  of  a  tooth  may  become  diseased 
because  the  irritating  action  of  certain  fillings  forms 
progressive  decay  under  a  filling  or  a  gold  or  porcelain 
jacket  crown.  It  is  usually  due  to  lack  of  oxygen  that 
such  cases  proceed  in  a  chronic  manner  and  often  large 
apical  granulomata  are  formed  without  symptoms  of 
disease.  If  the  pulp  of  such  teeth  is  opened,  it  often 
results  in  a  violent  subacute  attack  due  to  the  change  in 
the  oxygen  tension. 


PLATE     XIV 


Fig.  51 


Fig.  52 


Fig.  53 


Fig.  54 


Fig.  55 


Fig.  56 


Fig.  57 


Fig.  58 


Fig.  59 


Fig.  60 


Fig.  61 


Fig.  62 


Figs.  51,  52,  53,  54,  55  and  56. — Granulomata  caused  by  inefficient  root  canal  fillings. 
Figs.  57,  58  and  59. — Granulomata  from  decay  under  fillings  without  access  of  air. 
Figs.  60,  61  and  62. — Granulomata  occurring  on  crowned  teeth. 


Fig.  63. — Skull  of  Italian  showing  bony  destruction  caused  by  an  apical  granu- 
loma on  the  left  upper  second  bicuspid. 


ALVEOLAR  ABSCESSES  39 


Haematogenous  Infection.  Granulomata  usually  are 
due  to  direct  entrance  of  the  disease  through  the  root 
canal  but  may  also  be  caused  as  a  secondary  manifestation 
due  to  bacteremia,  that  is,  the  presence  of  the  microorgan- 
isms in  the  blood.  Any  devitalized  tooth  has  around  its 
apex  a  place  of  lowered  resistance  with  lowered  oxygen 
tension  due  to  the  destruction  of  nerve  and  blood  supply 
of  the  apex  and  contiguous  bone  areas,  a  destruction 
which  may  have  been  caused  by  the  use  of  caustic  and 
irritating  drugs  for  root  canal  medication  or  the  destruc- 
tive process  of  suppuration. 

Proliferating  Periodontitis.  The  poison- 
TH^Dis^ASE  ous  Pr0(lucts  °f  bacterial  decomposition 
and  fermentation  reach  the  peripheral 
tissues  of  the  tooth  and  stimulate  protective  new  growth. 
If  the  tooth  is  extracted  at  this  stage  we  find  a  marked 
thickening  of  slightly  reddish  character  at  the  apical 
region. 

Granuloma.  The  proliferation  usually  goes  on  until 
the  new  growth  has  reached  the  size  of  a  pea.  Larger 
granulomata  are,  however,  not  uncommon;  they  may 
reach  the  size  of  a  robin's  egg.  A  fibrous  layer  surrounds 
the  lesion,  which  is  very  thick  in  the  beginning  and  firmly 
attached  to  the  healthy  part  of  the  periodontal  membrane. 
The  extracted  tooth  usually  carries  with  it  such  a  granu- 
loma, or  so-called  abscess  sack.  Later,  when  the 
granuloma  reaches  larger  sizes,  it  becomes  thinner  and  is 
often  destroyed  by  fatty  degeneration,  which  decreases 
its  resisting  power  to  suppuration.  In  the  center  we  find 
the  seat  of  chronic  inflammation,  harboring  often  a  small 
amount  of  pus  or  other  products  of  degeneration  and 
absorption,  which  are  usually  taken  up  by  the  lymph  or 
capillary  system.  Destruction  of  bone  depends  upon  the 
progress  of  the  chronic  inflammation.  In  the  upper  jaw, 
where  the  apices  of  the  roots  are  close  to  the  facial  sur- 
face of  the  bone,  the  alveolar  plate  is  almost  always  de- 
stroyed; in  the  lower  jaw  it  is  a  most  infrequent  occur- 
rence to  find  the  thick  cortical  layers  of  the  mandible 


40  ORAL  ABSCESSES 


involved.  If  the  tooth  is  extracted  at  this  stage  the 
abscess  will  usually  remain  in  the  jaw  and  has  to  be  re- 
moved by  careful  curettage. 

The  microorganisms  which  inhabit  the  granuloma  have 
to  struggle  for  their  existence  in  this  tissue  which  is 
formed  by  lymphocytes,  leucocytes,  and  fibroblasts ;  pus, 
therefore,  is  formed  only  in  very  minute  quantity. 

Subacute  Attacks.  At  one  time  or  another  the  suppu- 
ration may  become  more  active  and  destroy  the  fibrous 
tissue  of  the  granuloma.  The  causes  of  such  acute  bac- 
terial activity  may  be  lowered  resistance  of  the  body  and 
wearing  out  of  the  cells,  whose  function  is  to  destroy  for- 
eign bodies.  It  may  come  from  a  change  in  oxygen  ten- 
sion, a  thing  with  which  almost  every  dentist  is  familiar, 
namely,  an  acute  attack  after  opening  into  the  pulp 
chamber  of  the  tooth  which  gives  the  air  a  chance  to  enter. 
It  also  may  be  caused  by  haematogenous  infection,  the 
invasion  of  another  kind  of  bacteria,  causing  a  mixed 
infection.  In  these  subacute  attacks  the  pus  usually  bur- 
rows a  sinus  to  the  gum,  the  tissues  react,  not,  however, 
very  actively,  as  in  the  acute  abscess,  because  partial  im- 
munization has  taken  place  in  the  tissues  surrounding 
the  chronic  condition.  After  the  pus  has  evacuated,  the 
signs  of  inflammation  usually  disappear  without  treat- 
ment and  the  sinus  closes  up.  This,  however,  does  not  in- 
dicate that  the  abscess  has  now  completely  healed,  but 
only  signifies  that  pus  formation  has  decreased  and  granu- 
lation predominates,  which  may  be  reversed  at  any  favor- 
able time. 

Exostosis  of  the  Root.  If  the  fibers  of  the  granuloma 
persist  for  a  long  time,  so  that  the  metabolism  of  the 
cementum  is  not  interfered  with,  the  constant  irritation 
from  the  chronic  inflammation  stimulates  the  activity  of 
the  cementoblasts  which  results  in  new  formation  of 
cementum,  which  we  call  exostosis  of  the  root.  This  usu- 
ally results  in  a  bulbous  form  at  the  apex  which  makes 
extraction  extremely  difficult. 

Necrosis  of  the  Root.  If  the  apical  part  of  the  peri- 
odontal  membrane   has   been    destroyed,    the   nutrient 


PLATE     XVI 


Fig.  64. — Skull  showing  bony  destruction  due  to  a  granuloma  caused  by  a 
left  upper  bicuspid,  bearing  a  gold  crown. 


PLATE     XVI  I 


1  •  .1    N 


Fig.  65 


Fig.  66 


Fig.  67 


i  v     X 


Fig.  68 


Fig.  69 


Fig.  70 


Fig.  71 


Fig.  72 


Fig.  73 


Fig.  74 


Fig.  75 


Figs.  65,   66,   67,   68,  69   and   70. — Radiographs   of  teeth  with   granulomata   showing  marked 

exostosis   of  the   roots. 

Figs.  71,  72  and  73. — Radiographs  of  teeth  with  necrosed  apices  due  to  granulomata. 

Figs.  74  and  75. — Radiographs  of  teeth  showing  large  osteomyelitic  area. 


ALVEOLAE  ABSCESSES  41 


supply  of  the  tooth  is  doubly  cut  off.  The  cementum, 
which  at  this  stage  contains  numerous  accessory  apical 
foramina  and  Haversian  canals,  soon  becomes  infected 
and  necrosed.  The  condition  then  is  that  of  bone  with 
the  periosteum  raised  and  no  blood  supply  from  within. 
Here  such  areas  become  separated  and  are  expelled  as 
sequestra.  In  the  tooth  this  cannot  take  place,  and  we 
must  consider  the  whole  organ  as  the  sequestrum  which 
is  retained  by  the  remaining  periodontal  membrane  at 
the  cervical  part  of  the  root.  In  some  cases,  chronic  in- 
flammation of  the  remaining  periodontal  membrane  sets 
in,  causing  necrosis  of  the  entire  root,  which  then  has  a 
greenish  appearance,  a  condition  which  is  often  spoken 
of  as  " gangrene  of  the  root." 

Resolution.  The  condition  of  chronic 
yfoivi        "  abscess  may  be  considered  the  termination 

for  the  larger  percentage  of  the  cases ;  it 
may  continue  for  years.  Resolution  never  occurs  with- 
out treatment. 

Chronic  Osteomyelitis.  The  bone  destruction,  occur- 
ring as  a  result  of  the  inflammatory  granulation,  involves 
an  osteomyelitis  even  at  its  early  stages.  Fortunately, 
nature  in  most  cases  prevents  an  extensive  involvement 
by  circumscribing  the  lesion  with  a  protective  layer  of 
fibrous  tissue  enclosing  the  seat  of  inflammation,  as  will 
be  shown  later  in  microscopic  pictures.  Osteomyelitis 
produced  by  such  conditions  is  much  less  severe  than  in 
other  parts  of  the  body  and  frequently  symptomless. 

Cysts.  There  has  been  much  writing  by  German  scien- 
tists tracing  root  cysts  of  larger  or  smaller  dimensions 
back  to  epitheliated  granulomata.  Dependorf  *  has  devo- 
ted a  large  amount  of  time  to  the  study  of  the  development 
of  such  cysts.  He  says  that  not  all  epitheliated  granulo- 
mata will  become  cysts,  and  that  cyst  formation  depends 
on  a  partial  and  concentric  degeneration  of  the  inner  part 
of  the  granuloma  first  of  all ;  secondly,  dependent  on  epi- 
thelium which  is  able  to  develop  and  proliferate,  and 
thirdly,  due  to  the  interference  with  the  blood  supply,  due 

*  See  Bibliography. 


42  ORAL  ABSCESSES 


to  the  chronic  inflammatory  conditions.  The  growth  of 
the  cyst  is  dependent  upon  chronic  inflammatory  condi- 
tions, which  are  enclosed  in  the  lumen  and  which  cause 
degeneration  of  the  larger  or  smaller  parts  of  the  central 
core.  The  inner  surface  becomes  lined  with  epithelium 
and  the  cyst  may  develop  to  almost  any  dimension.  It  is 
the  author's  opinion  that  cysts  may  form  from  epitheliated 
granulomata,  although  judging  from  the  number  of 
granulomata  which  do  not  form  cysts,  we  may  draw  the 
conclusion  that  such  a  formation  is  decidedly  rare- 

Proliferating  Periodontitis.  Local  symp- 
D I  AG  N  OS  IS  toms:  It  is  characteristic  of  the  prolifer- 
ating periodontitis  that  it  occurs  and  grows  without  caus- 
ing any  local  symptoms.  The  tooth  is  not  elongated 
because  the  growth  occurs  at  the  expense  of  the  bone. 
Sometimes,  however,  the  patient  has  a  sense  of  pressure 
over  the  tooth  and  often  the  pulsation  of  the  blood  is  felt 
in  the  vascular  granulation  tissue  around  the  apex,  espe- 
cially after  violent  exercise. 

General  symptoms:  In  the  beginning  stage  there  is 
rarely  any  systemic  involvement,  although  the  writer 
has  procured  streptococci  cultures  from  many  apices  of 
teeth  which  in  radiographs  showed  only  the  slightest  in- 
dication of  proliferating  periodontitis.  In  a  hospital 
case  of  endocarditis  such  a  small  area  prevented  entire 
recovery  and  the  removal  was  followed  by  rapid  improve- 
ment. 

Clinical  signs :  There  are  no  signs  which  would  indicate 
proliferating  periodontitis. 

Radiographic  examination:  With  the  intraoral  radio- 
graph we  can  diagnose  the  early  stages  of  periodontitis. 
The  dark  line  around  the  contour  of  the  root  which  repre- 
sents the  periodontal  membrane  is  thickened  at  the  apex, 
and  in  later  stages  we  find  distinct  areas  of  lessened  den- 
sity which  indicate  loss  of  bone  taken  up  by  the  prolifera- 
tion of  the  periodontal  membrane. 

Granuloma.  Local  symptoms:  The  granuloma  very 
frequently  gives  no  symptoms;  a  sense  of  pressure  and 
lameness  of  the  tooth  may  be  noticed  occasionally. 


ALVEOLAR  ABSCESSES  43 


General  symptoms:  At  this  stage  we  frequently  find 
complications  due  to  the  absorption  of  toxins  and  bac- 
teria. Malaise,  a  tired  feeling,  and  inability  to  do  a  day's 
work  is  a  frequent  indication  of  an  intoxication  which 
may  come  from  oral  lesions  besides  all  the  other  complica- 
tions mentioned  in  the  previous  chapter.  These  con- 
ditions should  be  recognized  and  inquired  into  and  looked 
at  as  a  reason  for  careful  diagnosis  of  the  mouth  by  means 
of  radiographs. 

Clinical  signs :  As  clinical  signs  are  absent  at  this  stage, 
it  is  of  greatest  importance  to  rely  on  radiographic 
diagnosis. 

Radiographic  examination:  The  granuloma  shows  in 
the  radiograph  as  a  circumscribed  area  of  decreased  den- 
sity and  is  easily  recognized  when  present  at  the  apex  of  a 
devitalized  tooth.  While  there  is  usually  little  doubt 
about  the  location  of  an  abscess  on  a  single-rooted  tooth, 
it  is  often  more  difficult  to  make  a  correct  diagnosis  on 
multirooted  teeth,  especially  the  upper  ones.  The  upper 
first  bicuspids  should  be  radiographed  from  a  bucco- 
mesial  direction,  while  two  radiographs  are  necessary  to 
show  distinctly  the  condition  of  the  two  buccal  roots  and 
the  palatal  root.  The  first  is  taken  about  perpendicular 
to  the  buccal  roots,  the  other  perpendicular  to  the  palatal 
root. 

Subacute  Attacks.  Local  symptoms:  If  suppuration 
becomes  more  active  in  the  granuloma,  the  patient  often 
feels  a  grumbling  and  lameness  of  the  tooth  which  may 
disappear  after  several  days.  In  other  instances,  the 
wall  of  the  granuloma  is  broken  down,  resulting  in  a  regu- 
lar subacute  attack.  The  patient  then  experiences  the 
symptoms  of  the  acute  abscess,  pain,  redness,  fever,  and 
swelling.  The  tissue,  however,  has  been  rendered  more 
or  less  immune,  and  the  symptoms  of  inflammation  are 
more  modified,  sometimes  hardly  noticeable,  at  other 
times  extreme.  The  condition,  however,  will  usually  pass 
through  the  stages  of  parulis  until  a  sinus  occurs  on  the 
gum  to  give  exit  to  the  accumulating  pus. 


44  OKAL  ABSCESSES 


General  symptoms:  The  general  symptoms  depend 
upon  how  severe  and  acute  the  attack  is.  There  may  be 
none  at  all,  or  they  may  be  equal  to  an  acute  process  pass- 
ing through  the  stages  of  parulis. 

Clinical  signs :  When  the  gum  over  the  abscess  is  found 
to  be  swollen  and  in  subacute  condition,  the  guilty  tooth 
is  usually  easily  located.  When  the  pulp  has  been  dead 
for  a  long  time,  electric  tests  will  give  negative  results, 
while  in  acute  conditions  there  is  usually  some  doubt, 
especially  if  the  nerve  fibres  of  the  pulp  have  not  been 
entirely  destroyed.  The  patient  usually  tells  upon  ques- 
tioning a  history  of  previous  attacks  or  treatment  of  the 
tooth. 

Radiographic  examination :  Radiographs  will  reveal  an 
area  of  lessened  density  on  a  devitalized  and  partly  filled 
root.  This  is  the  important  feature  of  differentiation 
between  an  acute  attack,  where  the  pulp  has  been  diseased 
only  recently  and  where  there  is  no  evidence  of  previous 
root-canal  work. 


PLATE     XVIII 


Fig.  76 


Fig.  77 


Fig.  78 


Fig.  79 


Fig. 


Fig.  81 


Fig.  82 


Fig.  83 


Figs.  76  and  77. — Radiographs  of  teeth  showing  small  areas  of  lessened  density  indicating 

periodontitis. 

Figs.   79,   80   and   81. — Radiographs   of  teeth  showing  large   areas   of  lessened   density 

indicating   grannlomata. 

Figs.  82  and  83. — Radiographs  of  teeth  with  subacute  abscesses.     The  root  canals  of  the 
teeth  have  been  partly  filled,  indicating  chronic  disease  of  long  standing. 


PLATE     XIX 


Fig.  84 


Fig.  85 


Fig.  86 


Fig.  87 


Fig.  88 


Fig.  89 


Fig.  90 


Fig.  91 


Figs.  84,  85  and  86. — Badiographs  of  teeth  showing  dark  areas  about  their  necks  representing  pus 

pockets  caused  by  mechanical  injury. 

Figs.  87,  88,  89  and  90. — Badiographs  of  teeth  showing  dark  areas   indicating  pus  pockets  at   the 

alveolar  border. 

Fig.  91. — Badiograph    showing  a  lower   incisor  with  an  apical  abscess  caused  by  pus  pockets,  mesial 

as  well  as  distal.     The  tooth  is  vital. 


CHAPTER  IV 


PATHOLOGICAL     DEVELOPMENT    AND     DIAG- 
NOSIS   OF    ALVEOLAR    ABSCESSES    DUE 
TO    OTHER    CAUSES    THAN    THE    DIS- 
EASE   OF    THE     DENTAL     PULP 

We  have  noted  in  the  preceding  chapter  that  the  largest 
percentage  of  the  oral  abscesses  are  due  to  diseases  of  the 
dental  pulp.  However,  other  forms  of  abscesses  in  and 
around  the  alveolar  process  occur  which  are  due  to  dif- 
ferent causes.  These  sometimes  give  almost  the  same 
symptoms  as  some  of  the  already  described  types  and  it  is 
important  to  distinguish  them  because  their  treatment 
is  so  widely  different. 

According  to  the  etiological  factor  we  can  distinguish 
alveolar  abscesses  due  to  diseases  of  the  gum  and  alveolar 
abscesses  due  to  difficult  eruption,  impaction  and  un- 
erupted  teeth. 

1.     Alveolar  Abscesses  due  to  Diseases  of  the  Gum. 

etiology  Injury  of  the  Gum.    The  gum  is  occasion- 

ally injured  by  the  use  of  a  toothpick  or  a 
bristle  of  a  toothbrush  which  may  become  lodged  between 
the  gingival  margin  and  the  tooth.  An  inflammation  may 
occur  if  the  wound  had  been  infected,  involving  not  only 
the  gum  but  frequently  the  cervical  part  of  the  periodon- 
tal membrane  and  the  periosteum,  resulting  in  a  marginal 
periodonditis  with  subgingival  parulis  formation.  Other 
causes  are  poor  fillings,  either  projecting  into  the  gum  or 
lacking  in  contour,  faulty  bands  and  gold  crowns,  which 
project  into  the  gum  instead  of  being  closely  fitted  around 
the  neck  of  the  tooth.  After  the  cement  by  which  they 
are  fastened  has  washed  away,  these  places  will  harbor 


46  ORAL   ABSCESSES 


contaminated  food  and  be  the  seat  of  fermentation  and 
later  suppuration.  A  similar  condition  occurs  under 
fixed  bridges,  which  can  be  properly  cleaned  neither  by 
patient  nor  dentist,  the  gum  becomes  inflamed,  and  after 
the  removal  of  the  bridge  we  often  discover  an  extensive 
ulcerated  area.  The  vile  odor  which  is  released  after 
removing  such  appliances  speaks  for  itself  and  makes 
superfluous  further  comment  as  to  its  unsanitary  and 
disease  breeding  properties. 

Pus  Pockets.  Pus  pockets  such  as  are  characteristic 
of  pyorrhoea  alveolaris  sometimes  become  closed  up. 
This,  or  any  other  reason  which  prevents  the  pus  from 
escaping  at  the  cervical  margin,  causes  accumulation  of 
pus  or  abscess  formation. 

In  abscesses  caused  by  injury  of  the  gum, 

the  disease  ^e  ^n^ec^on  i-s  usually  superficial.  The 
pus  is  seldom  formed  under  the  perios- 
teum, but  accumulates  between  the  periosteum  and  gum 
in  the  submucosa  of  the  mucous  membrane.  A  red  swel- 
ling is  formed  at  the  gingival  margin,  a  small  parulis, 
which  heals  spontaneously  after  it  breaks  or  after  an  in- 
cision is  made.  In  more  deep-seated  cases  the  ligamen- 
tum  circulare  and  periodontal  membrane  may  become 
infiltrated.  The  Haversian  canals  then  become 
infected,  causing  destruction  of  the  cervical  part  of  the 
alveolar  process.  If  pus  pockets  such  as  occur  in  py- 
orrhoea alveolaris  or  other  forms  of  marginal  periodon- 
titis are  the  cause  of  the  abscess,  the  accumulation  of  pus 
is  usually  more  deeply  seated  than  in  the  case  of  injury 
of  the  gum.  On  account  of  the  closure  of  the  natural 
outlet  at  the  cervical  margin  the  pus  will  invade  the  alve- 
olar process  and  find  its  way  to  the  surface  of  the  gum. 
The  process  usually  passes  through  the  stages  of  subperi- 
osteal and  subgingival  parulis,  which,  however,  gives  no 
very  severe  symptoms  as  the  tissues  have  been  pretty 
well  immunized  by  the  long  existing  chronic  inflamma- 
tion. This  destructive  process  may,  however,  be  halted 
any  time  if  the  outlet  at  the  gum  margin  is  reopened,  when 
the  disease  continues  in  its  former  chronic  form. 


ALVEOLAR   ABSCESSES  47 


diagnosis  Local  and  general  symptoms:  The  pa- 
tient  experiences  about  the  same  discom- 
fort as  in  the  parulis  formation  already  described,  only 
perhaps  in  a  modified  way,  because  the  tissue  has  almost 
always  been  more  or  less  immunized  by  a  preexisting  and 
causative  chronic  condition,  as  in  pyorrhoea,  or  because 
the  abscess  is  very  superficial  and  little  destruction  is 
necessary  to  form  an  outlet  for  the  discharge. 

Clinical  signs:  Upon  examination,  a  tumor-like  swel- 
ling is  seen  nearer  the  gum  margin  than  in  true  alveolar 
abscess  and  parulis.  The  surrounding  tissues  are  less 
involved.  There  is  usually  no  history  of  pulp  disease; 
the  tooth  may  be  vital  or  devitalized.  The  patient  often 
remembers  that  the  gum  had  been  injured  or  there  may  be 
indication  of  pyorrhoea  from  the  general  condition  of  the 
mouth.  The  differential  diagnosis  may  be  established  by 
the  radiograph. 

Radiographic  examination:  Very  often  we  are  left  in 
doubt,  whether  we  have  to  deal  with  a  true  alveolar  ab- 
scess, caused  by  a  diseased  pulp,  or  whether  the  condition 
is  wholly  periodontal.  Especially  doubtful  cases  are  those 
where  the  tooth  has  a  gold  crown  or  large  fillings,  as  both 
are  conditions  which  indicate  the  involvement  of  the  pulp. 
The  importance  of  knowing  whether  the  pulp  is  involved 
or  not  is  evident  if  we  consider  the  first  and  most  impor- 
tant therapeutic  measure,  the  removal  of  the  cause.  A 
radiograph  will  help  a  great  deal  in  diagnosis;  if  there 
is  no  area  of  lessened  density  at  the  apex  of  the  tooth,  we 
know  that  the  abscess  is  not  formed  from  a  dead  pulp, 
and  often  we  see  a  large  dark  area  at  the  neck  of  the  tooth 
indicating  marginal  destruction  of  the  alveolar  process 
due  to  a  gingival  abscess  or  parulis. 

2.  Alveolar  Abscess  Due  to  Difficult  Eruption,  Im- 
paction or  Unerupted  Teeth. 

etiology      Difficult  eruption  and  partial  impaction: 

The  lower  third  molar  is  the  tooth  which 

most  frequently  is  impacted,  but  also  the  upper  third 

molar  is  often  in  irregular  position.  The  reason  is  that  the 


48  OKAL  ABSCESSES 


third  molars  are  the  last  teeth  to  take  their  places  in  the 
dental  area,  and  as  the  jaw  is  often  too  short  (a  result  of 
civilization)  to  accommodate  all  the  teeth,  the  third  molar 
becomes  locked  under  the  bulging  of  the  crown  of  the 
second  molar.  In  the  lower  jaw  there  is  an  additional 
obstacle,  the  ascending  ramus,  the  terminal  boundary  of 
the  part  of  the  mandible  that  accommodates  the  teeth. 
The  cuspid  teeth  are  the  next  in  the  series  which  are  most 
likely  to  be  impacted,  the  reason  being  that  the  tooth  in 
abnormal  conditions  does  not  appear  until  long  after  the 
lateral  incisors  and  the  first  bicuspids  are  in  place.  While 
the  lower  third  molars  and  cuspids  are  most  likely  to  be 
impacted,  any  tooth  in  the  lower  as  well  as  the  upper  jaw 
may  become  impacted  if  the  space  which  they  are  to  oc- 
cupy is  taken  up  by  other  teeth,  or  if  the  malposition  has 
been  assumed  at  an  early  period  during  the  development 
of  the  tooth  germ. 

Inflammation  may  start  before  the  tooth  has  pierced 
the  gum,  from  the  irritation  caused  by  biting  on  the  tissue 
overlying  the  occlusal  surface  of  the  tooth.  In  most 
cases,  however,  the  infection  occurs  after  the  gum  has 
been  pierced  by  the  erupting  cusps  and  may  be  due  to 
food  and  fluids  of  the  mouth  entering  through  this  wound. 
The  soft  tissue  does  not  adhere  to  the  enamel  of  the  crown, 
as  it  does  to  the  cementum  on  the  root  by  means  of  the 
periodontal  membrane  and  ligamentum  circulare,  and 
therefore  foreign  material  is  free  to  pass  deep  into  the 
tissue  around,  slowly  erupting  teeth  both  impacted  and 
normal.  In  other  cases  the  infection  is  due  more  to  irri- 
tation of  the  gum,  which  is  crowded  over  the  occlusal  sur- 
face during  mastication  and  becomes  bruised  by  the  teeth 
of  the  opposite  jaw.  In  such  conditions  inflammation 
again  sets  in  and  is  maintained. 

Unerupted  Impacted  Teeth.  In  some  cases  teeth  grow 
in  an  entirely  horizontal  or  even  downward  direction 
and  are  so  interlocked,  that  it  is  impossible  for  them  to 
come  to  the  surface.  Such  teeth  may  lie  dormant  for 
several  years  but  at  any  time  may  suddenly  become  asso- 
ciated with  active  pathological  conditions,  when  exert- 
ing pressure  on  the  tissue  towards  which  they  grow.     It 


PLATE     XX 


Fig.  92 


Fig.  93 


Fig.  94 


Fig.  95 


Fig.  96 


Fig.  97 


Fig.  98 


Figs.   92,   93,   94  and   95. — Radiograph  showing   dark   areas  indicating  abscesses  caused  by  impacted 
but  partly  erupted  wisdom  teeth.        In  Fig.  93  the  pulp  has  been  involved  and  periodontitis  caused  at 

the  apex. 

Fig.  96,  97  and  98. — Radiographs  of  unerupted  molars  showing  dark  areas  indicating  abscesses. 


PLATE     XXI 


Fig.  99 


Fig.  100 


Fig.  101 


Fig.  102 


Fig.  103 


Fig.  104 


Fig.  105 


^ 


Fig.  106 


Fig.  107 


Fig.   99. — Radiograph   showing  impacted   second   and  third  molar. 

Fig.  100. — Kadiograph  shows  impacted  second  molar  which  had  been  broken  off.     The  third  molar 

is  partly  erupted  and  prevents  the  second  molar  from  coming  up. 

Figs.  101  and  102.— Radiographs  show  impacted  temporary  molars. 
Figs.  103,  104,  105,  106,  107  and  108. — Radiographs  show  other  impactions  causing  more  or  less  troubh 


ALVEOLAE   ABSCESSES 49 

seems  to  be  a  physio-pathological  law  that  any  abnormal 
pressure  in  the  body  causes  resorption  of  the  part  most 
easily  dissolved.  This  in  turn  forms  a  place  of  lowered 
resistance  and  is  liable  to  infection.  Infection  may  occur 
from  a  blind  abscess  on  a  neighboring  tooth  or  through 
the  blood. 

After  the  infection  has  taken  place  the 

the:  di<5e-a«sf  Process  °f  inflammation  may  take  on  a 
chronic  course.  This  is  especially  the 
case  if  there  is  an  outlet  for  the  pus  through  the  gingival 
opening  made  by  the  erupting  tooth.  This  outlet,  how- 
ever, is  rarely  adequate,  pus  is  accumulated  and  when 
under  pressure  is  forced  deeper  into  the  bone  as  well  as 
into  the  soft  tissue.  The  inflammation  then  extends  to 
the  adjoining  parts,  involving  the  fauces,  mucous  mem- 
brane and  muscles  about  the  ramus.  A  pharyngitis  often 
sets  in,  trismus  of  the  muscles  of  mastication  is  of  common 
occurrence,  and  deglutition  becomes  difficult.  The  abscess 
usually  passes  through  the  stages  of  alveolar  parulis,  and 
the  trismus  becomes  so  marked  that  the  patient  is  unable 
to  open  his  mouth.  At  this  time  usually  there  is  a  sinus 
formed,  the  pus  evacuates  and  the  movements  of  the  jaw 
become  less  constrained.  If  no  surgical  procedure  res- 
tores the  condition  to  normal,  the  patient  may  have  recur- 
rent attacks  of  the  same  character  at  frequent  intervals. 
If  the  impacted  tooth  causes  absorption  of  another  tooth, 
this  is  sometimes  carried  so  far  as  to  involve  its  pulp. 
Such  conditions  cause  severe  neuralgic  pains,  and  if  the 
pulp  becomes  infected  severe  alveolar  abscesses. 
diagnosis  Local  symptoms:  The  local  symptoms 
are  usually  well  marked  but  not  character- 
istic or  distinctive  of  the  cause.  There  is  intense  pain, 
sometimes  almost  unbearable,  referred  to  the  ear,  eye, 
forehead,  or  opposite  jaw.  If  the  condition  is  due  to  a 
third  molar,  the  patient  complains  of  a  sore  throat  and 
inability  to  swallow ;  often  the  mouth  can  be  opened  but 
very  little.  There  may  be  extreme  swelling  of  the  face  on 
the  affected  side ;  at  other  times  the  external  swelling  is 
less  marked,  all  the  infiltration  being  on  the  inside  of  the 
mouth. 


50  ORAL  ABSCESSES 


General  symptoms:  There  is  usually  fever  up  to  104° 
F.,  general  malaise,  and  the  patient  often  presents  serious 
symptoms,  especially  if  severe  pain  has  caused  continual 
loss  of  sleep. 

Clinical  signs:  If  a  third  molar  is  the  cause  of  the 
trouble,  examination  of  the  mouth  is  often  very  difficult. 
.Ankylosis  should  be  excluded,  which  is  a  disease  of  the 
mandibular  joints  and  is  usually  not  accompanied  by 
severe  pain  or  temperature.  Pus  can  frequently  be 
pressed  from  the  swelling  and  often  a  white  cusp  is  seen 
sticking  out  from  the  inflamed  gum.  If  we  have  to  do 
with  an  unerupted  tooth  the  radiograph  will  be  the  only 
means  by  which  a  positive  diagnosis  can  be  made. 

Radiographic  diagnosis:  The  radiograph  is  a  most 
valuable  means  of  detecting  the  real  cause  of  the  trouble 
and  is  furthermore  a  valuable  aid  in  determining  the 
mode  of  operation.  Partly  erupted  impacted  teeth  can 
be  taken  on  small,  intraoral  films,  but  unerupted  teeth 
should  be  taken  on  large  extraoral  films  or  plates,  because 
there  is  a  possibility  of  malposition.  Third  molars  have 
been  found  in  the  ramus  as  far  up  as  the  mandibular  notch 
and  as  low  down  as  the  angle  of  the  ramus,  places  which 
cannot  be  reached  with  intraoral  pictures.  For  impacted 
upper  teeth  in  the  anterior  region  of  the  mouth,  a  large 
film  placed  between  the  teeth  with  an  exposure  from  well 
above  the  head  will  give  in  most  cases  good  results.  For 
impacted  cuspids  in  the  lower  jaw  the  rays  should  be 
directed  somewhat  from  underneath,  as  these  teeth  are 
often  situated  as  low  as  the  lower  border  of  the  mandible. 
Stereoscopic  radiographs  would  be  more  desirable  in 
many  cases,  as  an  ordinary  radiograph  is  flat  and  does  not 
give  the  exact  location  of  the  tooth.  For  example,  you 
cannot  tell  whether  the  impacted  cuspid  in  Figure  107  is 
external  or  internal  to  the  other  teeth ;  however,  the  tak- 
ing of  stereo-radiographs  requires  a  great  deal  of  skill  and 
necessitates  the  use  of  special  apparatus.  The  stereo- 
radiographic  technique  is  still  in  the  process  of  develop- 
ment ;  good  results,  however,  can  be  obtained,  and  in  diffi- 
cult cases  these  pictures,  which  give  a  perspective  view, 
are  of  great  value. 


PLATE     XXII 


Fig.  109. — EadiograpMe  plate  showing  an  impacted  upper  third  molar  in  the  pos- 
terior wall  of  the  antrum.  Symptoms  covering  a  period  of  one  year  prior  to  its 
discovery:  Periodical  unilateral  headaches,  with  ent're  absence  of  nu,  but  bad 
taste  in  the  mouth  every  morning.  There  is  a  sinus  opening  just  back  of  the 
second  molar.     The  tooth  discharges  half  a  dram   of  pus  in  twenty-four  hours. 

Reproduced  by  courtesy  of  Dr.  Gibbons.    Radiograph  by  Dr.  A.  TV.  George. 


PLATE     XXIII 


Fig.  110. — Radiographic  plate  by  which  an  unerupted  lower  third  molar  was 
discovered  at  the  angle  of  the  jaw.     Note  the  large  cyst. 


CHAPTER  V 


PATHOLOGICAL     DEVELOPMENT    AND     DIAG- 
NOSIS  OF  ABSCESSES  OF  THE  TONGUE 
AND   SALIVARY   GLANDS    AND    DUCTS 

Thus  far  abscesses  occurring  in  and  about  the  mandi- 
bular and  maxillary  bones  have  been  described;  these 
are  by  far  the  most  common  ones.  The  tongue  and  sali- 
vary glands  are,  however,  occasionally  the  seat  of  abscess 
conditions. 

1.     ABSCESSES  OF  THE  TONGUE 

The  tongue  is  comparatively  rare  as  the  seat  of  inflam- 
mation and  infection,  but  if  abscesses  of  the  tongue  occur, 
we  have  a  condition  which  may  bear  grave  results. 
Diffuse  infiltration  frequently  occurs  and  often  spreads 
to  the  posterior  part  of  the  tongue,  and,  on  account  of  its 
increased  size,  causing  difficulty  in  breathing  which  often 
can  be  relieved  only  by  tracheotomy. 
. „-.„.-,         Three  varieties  of  tongue  abscesses  shall 

VAR5ET8ES  u      j  .i     j  ° 

be  described. 

1.  The  simple  abscess  of  the  tongue. 

2.  The  phlegmonous  abscess  of  the  tongue. 

3.  The  tubercular  abscess  of  the  tongue. 

1.     Tide  Simple  Abscess  of  the  Tongue. 
^^.«.  ~~w  Circumscribed  abscess  formation  of  the 

ETIOLOGY  ,  »,         -,        , 

tongue  is  very  oiten  due  to  injury  or  en- 
trance into  the  tongue  of  a  foreign  body,  such  as  a  fish 
bone,  during  mastication.  More  often,  however,  there 
are  sharp,  broken-down  teeth  which  cause  the  primary 


52  ORAL  ABSCESSES 


injury,  and  if  such  teeth  are  abscessed,  discharging  pus 
from  sinus  or  pocket,  the  wound  at  once  becomes  infected. 

~.  .*.._..         The  infection  usually  assumes  a  more  or 
CLINICAL         ii-  x 

course  chronic  appearance,  causing  a  tumor- 

like thickening  at  the  infected  part.  If  no 
therapeutic  interference  occurs,  the  abscess  may  break, 
but  more  frequently  it  will  end  in  the  phlegmonous  type. 
„..„MAeie  Local  symptoms:  The  simple  abscess  of  the 
tongue  causes  more  or  less  local  discomfort. 
The  place  where  the  lesion  occurs  is  extremely  tender  to 
touch,  causing  difficulty  in  eating  and  speaking. 

Clinical  signs:  If  the  tongue  is  palpitated,  one  can 
feel  distinctly  a  hard  swelling  in  the  substance  of  the  lin- 
gual muscle ;  the  tongue  is  usually  slightly  enlarged,  which 
causes  indentations  on  its  sides  because  it  is  crowded 
into  the  interdental  spaces.  In  the  first  stages  it  may  be 
hard  to  differentiate  this  lesion  from  gummata  and  tu- 
mors, but  later  when  the  signs  of  inflammation  are  more 
marked  and  when  there  is  discharge  of  pus,  there  is 
usually  no  doubt  about  the  diagnosis.  An  exploratory 
incision  or  puncture  may  be  made ;  this  should  be  deep 
enough  to  reach  the  seat  of  trouble  and  will,  if  pus  is 
drawn,  verify  the  diagnosis. 

2.     The  Phlegmonous  Abscess  of  the  Tongue. 

etiology  Injuries  due  to  infected  foreign  bodies,  as 
already  described,  and  injury  from  carious 
teeth  surrounded  by  septic  conditions  very  often  take  on  a 
more  acute  form  than  the  one  just  described.  Progressive 
alveolar  abscesses  may  also  cause  phlegmonous  abscesses 
of  the  tongue,  if  their  course  involves  the  deeper,  posterior 
lingual  muscles. 

In  the  phlegmonous  abscess  of  the  tongue,  a  purulent 
or  fibrino-purulent  infiltration,  causes  a  diffuse  swelling. 
The  size  of  the  tongue  increases  rapidly,  the  anterior 
part  is  pushed  forward  and  no  longer  has  room  between 
the  teeth.     The  soft  palate  and  the  mould  are  pushed 


PLATE      XXIV 


Fig.  11 L 


Fig.  112 


Fig.  111. — Simple  abscess  of  the  tongue. 
Fig.  112. — Tubercular  abscess  of  the  tongue. 


TONGUE,  SALIVARY  GLANDS    AND  DUCTS 


upward  and  the  epiglottis  downward  into  the  larynx.  In 
severe  cases,  swallowing  is  impossible,  causing  the  saliva 
to  flow  out  of  the  month,  and  even  breathing  is  rendered 
difficult.  If  the  epiglottis  becomes  enlarged  by  oedematic 
swelling,  tracheotomy  may  be  necessary,  but  more  often 
the  disease  is  less  grave,  pus  discharge  occurring  sooner 
or  being  facilitated  by  early  surgical  interference,  which 
is  possible  if  the  center  of  the  infection  can  be  located. 
diagnosis  -k°cal  symptoms:  The  patient  complains 
of  the  tongue  being  swollen  and  too  large,  of 
difficulties  in  swallowing  and  breathing.  If  the  tongue 
comes  in  contact  with  hard  food,  it  causes  a  great  deal  of 
pain  and  the  saliva  often  flows  from  the  mouth. 

General  symptoms:  The  pulse  is  generally  increased 
in  rate,  the  temperature  rises,  and  may  reach  the  high 
marks  of  septic  conditions. 

Clinical  signs:  Examination  of  the  mouth  is  usually 
impossible  on  account  of  the  muscular  trismus  and  the 
sensitiveness  of  the  tongue  to  touch.  The  cervical  and 
submaxillary  lymph  glands  are  involved  at  an  early  stage 
of  the  disease  and  are  extremely  tender  to  touch.  Later 
there  is  marked  angina,  causing  the  patient  to  bend  the 
head  forwards  on  the  chest,  which  somewhat  facilitates 
the  breathing  through  the  nose. 

3.     Tubercular  Abscesses  of  the  Tongue. 

Tubercular  abscesses  of  the  tongue  may  be 
primary  or  secondary  infections.  Tubercu- 
lar bacilli  are  found  in  mouths  of  healthy  persons  and 
primary  tubercular  infections  may  therefore  occasionally 
occur  at  an  injured  part  of  the  tongue.  This,  however, 
is  said  to  be  a  rare  condition.  Secondary  infection  is 
more  common,  slight  wounds  on  the  tongue  caused  by 
carious  teeth  or  sharp  artificial  dental  prostheses  are 
easily  infected  by  the  bacilli  of  the  saliva  and  expecto- 
rated material. 


54  ORAL   ABSCESSES 


Tubercular  abscesses  of  the  tongue  occur 
course  mostly  on  the  tip,  the  sides,  and  the  mucous 
membrane  reflection  between  tongue  and 
floor  of  the  mouth.  When  first  seen  they  are  very  small 
nodules  of  yellow.  A  clear  infiltration  develops,  becom- 
ing gradually  thick  and  increasingly  visible.  The  lesion 
usually  extends  deep  into  the  substance  of  the  tongue, 
developing  a  fissure  or  an  ulcer.  Tuberculosis  fissures  are 
very  short,  often  stellate  or  branching,  and  are  generally 
single.  The  margin  is  indicated,  causing  an  elevation  of 
the  edges  which  are  liable  to  caseate,  forming  a  foul  and 
ragged  surface.  The  tuberculosis  ulcer  is  the  more  ag- 
gressive form  of  the  fissures  and  presents  edges  which  are 
a  little  thrown  up,  but  not  undermined,  and  are  usually 
sharp  in  outline.  The  secretion  is  small  in  quantity  and  is 
of  grayish  yellow  color.  Pale  red  flesh  warts,  and  here 
and  there  small  gray  knots  may  be  visible. 
diagnosis  -k°cal  symptoms:  Tuberculosis  of  the 
tongue  is  seldom  noticed  early  by  the  pa- 
tient, as  the  lesions  first  are  very  small  and  produce  no 
symptoms;  later  they  become  tender  and  pain  becomes 
pronounced. 

General  symptoms:  The  patient  may  suffer  from 
pulmonary  tuberculosis  or  lupus  of  the  face.  However, 
he  may  be  perfectly  well,  the  lesion  of  the  tongue  being  a 
primary  infection. 

Clinical  signs:  The  appearance  of  the  tubercular  le- 
sions of  the  tongue  has  already  been  described.  Bacteri- 
ological examination  of  the  sputum  and  excretions  is 
important  for  making  a  sure  diagnosis.  A  negative 
Wasserman  test  excludes  gummata,  but  carcinoma  of  the 
tongue  is  often  difficult  to  differentiate  from  tuberculosis 
with  certainty. 

II.    ABSCESSES  OF  THE  SALIVARY  GLANDS  AND  DUCTS 

Abscesses  of  the  salivary  glands  and  ducts  may  be 
divided  into  primary  and  secondary  infections.  The  sub- 
lingual and  submaxillary  glands  are  most  frequently 


TONGUE,  SALIVAKY  GLANDS   AND  DUCTS  55 

involved  by  primary  infection,  the  disease  entering 
through  the  salivary  ducts.  The  parotid  gland  is  more 
often  the  seat  of  secondary  infection,  the  bacteria  entering 
the  gland  through  the  circulation.  Salivary  calculi  are 
also  to  be  considered.  They  may  either  cause  or  be 
caused  by  infection. 

etiology  Primary  Infection.  The  primary  infection 
of  the  salivary  glands  may  be  due  to  a  con- 
tinuous septic  process,  such  as  necrosis  or  ostitis  of  the 
mandible,  or  alveolar  abscesses  from  lower  teeth.  The 
pus  burrows  through  the  tissue,  following  the  path  of 
least  resistance,  and  often  reaches  the  submaxillary  gland, 
causing  Ludwig's  angina,  a  disease  which,  however,  is  not 
restricted  to  the  submaxillary  gland,  but  attacks  the 
muscles  of  the  floor  of  the  mouth  and  neck.  More  com- 
monly, however,  the  infection  enters  by  way  of  the  ducts, 
originating  from  pus  discharged  by  sinuses  of  abscessed 
teeth,  pyorrhoea  pockets,  or  other  forms  of  oral  sepsis. 

Secondary  Infections.  Haematogenous  infection  of 
the  parotid  gland  is  known  to  occur  occasionally  after 
infectious  diseases,  such  as  scarlet  fever,  typhoid  fever, 
measles,  meningitis,  appendicitis,  chalecystitis,  and  acute 
abscesses.  Any  focus  causing  secondary  infection  seems 
therefore  to  cause  disease  of  the  parotid  gland  and  in  very 
rare  cases  of  the  other  salivary  glands. 

Salivary  calculi.  Calculi  are  more  commonly  found 
in  the  sublingual  and  submaxillary  ducts  and  glands  and 
are  of  rather  rare  occurrence  in  the  parotid  gland.  The 
question  whether  the  calculus  is  primary  or  secondary  to 
the  infection  has  not  yet  been  entirely  settled.  The  be- 
lievers in  the  primary  origin  of  the  calculi  think  that  the 
infection  is  due  to  its  irritating  presence.  The  men  who 
believe  in  the  infectious  origin  of  the  calculi  founded 
their  idea  upon  microscopic  investigations.  They  think 
that  calcium  phosphate  or  carbonate  is  deposited  in  con- 
centric fashion  around  organic  exudates  as  epithelial  cells, 
leucocytes,  bacterial  emboli,  or  mucin,  or  that  precipita- 
tion of  the  salts  may  be  due  to  direct  bacterial  activity. 


56  ORAL  ABSCESSES 


Whether  primary  or  secondary,  the  calculus  plays  an 
important  role  in  the  infections  of  the  salivary  glands, 
and  cases  which  will  not  yield  to  treatment  and  which 
recur  often  harbor  in  their  ducts  or  glandular  substance 
calculi  which  are  a  source  of  irritation  and  reinfection. 

Stones  may  be  found  in  Stenson's  or  Wharton's  duct 
or  in  the  body  of  the  glands.  They  most  frequently  occur 
in  Wharton's  duct  and  the  sublingual  gland. 
clinical  ^  ^e  disease  starts  from  the  mouth,  the 
course  infection  often  does  not  progress  farther 
than  a  short  distance  through  the  duct.  The 
duct  walls  become  swollen,  accumulation  of  products  of 
infection  occurs,  and  calculi  may  be  formed.  Either  con- 
dition obstructs  the  flow  of  saliva.  During  the  time  of 
glandular  activity,  at  meal  times,  and  if  tasty  food  is  seen, 
a  tumor  like  a  swelling  will  occur  at  the  site  of  the  obstruc- 
tion, causing  more  or  less  pain  until  the  duct  is  suffi- 
ciently dilated  to  allow  excretion.  Abscess  formation 
usually  occurs,  discharging  either  through  the  duct  or 
forming  a  new  sinus  to  the  mouth. 

In  ascending  duct  infections,  the  process  spreads 
through  the  accessory  ducts,  finally  involving  the  glands 
and  interlobular  tissue.  In  the  parotid  gland  the  abscess 
may  point  towards  the  face,  the  mouth,  the  external 
auditory  canal,  or  may  extend  upwards  into  zygomatic 
fossa.  In  the  submaxillary  and  sublingual  gland,  the 
abscess  will  break  either  to  the  mouth  or  through  the  floor 
of  the  mouth  to  the  skin  of  the  submandibular  region  or 
the  neck.  The  salivary  fistula  occuring  in  this  fashion 
is  extremely  difficult  to  heal  and  often  can  be  closed  only 
by  radical  surgical  procedures. 

In  the  secondary  infections  the  bacteria  are  carried 
to  the  glands  in  the  blood  stream  and  the  abscess  starts 
in  a  blood  vessel  and  progresses  to  the  adjacent  parts. 
diagnosis  ^oca^  symptoms:  The  patient  usually  com- 
plains  of  marked  swelling  in  the  region  of 
the  gland  which  may  frequently  change  its  size.  If  the 
duct  is  affected,  the  swelling  becomes  especially  marked 
during  glandular  activity.     If  the  abscess  and  stone  lie 


PLATE     XXV 


Fro.  113 


Fig.  114 


Fig.  113. — Swelling  under  the  tongue  on  the  left  side. 

Fig.  114. — Eadiograph  showing  salivary  calculus  causing 

the  condition  indicated  in  the  picture  above. 


TONGUE,  SALIVARY  GLANDS    AND  DUCTS  57 

in  the  substance  of  the  gland,  the  swelling  is  usually  of  a 
more  inflammatory  nature.  At  times,  due  to  some  un- 
known factor,  probably  renewed  bacterial  activity,  there 
are  sudden  reactions  and  the  patient  complains  of  intense 
pain.  Such  attacks  occur  at  irregular  intervals  and 
cause  a  large  amount  of  suffering. 

Clinical  signs:  During  the  attacks,  we  usually  find 
the  characteristic  symptoms  of  acute  abscess  formation 
with  more  or  less  swelling  of  the  neighboring  tissue,  which 
is  not  alone  due  to  the  accumulation  of  saliva  in  the  gland, 
but  to  oedematic  infiltration,  especially  so  in  streptococcic 
infection.  The  corresponding  lymph  glands  are  en- 
larged, soft,  and  tender  in  acute  conditions,  hard  and 
solid  in  cases  of  longer  standing,  which  have  passed  more 
or  less  into  a  chronic  stage.  There  may  be  discharge  of 
sero-purulent  material  through  the  inflamed  orifice  of 
the  duct  or  a  fistular  bidigital  palpitation  and  careful 
exploration  of  the  duct  with  a  fine  silver  probe  may  reveal 
a  stone,  but  if  the  trouble  is  harbored  in  the  gland  itself, 
this  method  of  diagnosis  will  be  found  unsuccessful. 

Radiographic  examination:  Radiographic  diagnosis 
is  of  greatest  importance  in  glandular  affections.  Extra- 
oral,  as  well  as  intraoral  films,  are  of  greatest  value ;  they 
not  only  tell  us  whether  there  are  calculous  obstructions, 
but  also  give  us  their  location,  a  helpful  aid  for  the  opera- 
ting procedure.  For  sublingual  calculi  and  stones  in 
Wharton's  duct,  a  large  film  may  be  placed  between  the 
patient's  teeth,  the  head  being  bent  in  an  extreme  back- 
ward position  so  that  the  rays  can  be  directed  from  the 
submandibular  region  vertically  on  the  film.  Submaxil- 
lary calculi  may  be  taken  by  the  same  method  or  by  plac- 
ing a  film  or  plate  under  the  mandible,  more  towards  the 
diseased  side,  reaching  farther  back  than  the  angle  of 
the  jaw.  The  picture  is  taken  from  above  with  the  mouth 
wide  open. 

The  treatment  of  the  abscesses  of  the  tongue  and  sali- 
vary glands  will  be  found  in  the  general  chapter  of  treat- 
ment of  abscesses. 


CHAPTER  VI 


BACTERIOLOGY  OF  ORAL  ABSCESSES 

importance    The  careful  scientific  study  of  the  bacteria 
OF  the  found  in  oral  abscesses  requires  a  great 

ogkJaiTstudy  ^ea*  °^  ^me  an(^"  Patience  on  account  of 
the  many  varieties  which  normally  in- 
habit the  mouth.  These  may  become  the  direct  cause  of 
abscesses  or  inhabit  the  lesions  accidentally,  living  upon 
the  products  of  decomposition.  It  is  especially  the  culti- 
vation and  isolation  of  the  anaerobic  bacteria  which  ren- 
ders the  investigations  difficult.  No  one  has  been  able  to 
demonstrate  that  one  type  of  bacteria  causes  one  typical 
form  of  dental  abscess  and  it  has  generally  been  accepted 
that  any  one  of  the  pyogenic  bacteria  may  cause  abscesses 
in  the  mouth.  It  has  been  observed  and  demonstrated 
that  it  is  not  so  much  the  variety  of  the  bacteria  which 
determines  the  course  of  the  disease  but  that  it  depends 
upon  the  number,  vitality,  and  virulence  of  the  invading 
organisms  and,  moreover,  upon  the  abundance  or  scarcity, 
as  quality  of  the  media ;  such  as  organic  matter  in  the  root 
canal,  whether  an  abscess  will  develop  as  an  acute  or 
chronic  condition.  But  also  secondary  invasions  of  bac- 
teria and  the  different  combinations  of  mixed  infections 
determine  slight  changes  in  the  pathological  picture,  such 
as  the  production  of  gases,  odor  of  the  exudates,  and  color 
of  the  pus.  The  variations,  however,  are  so  manifold  and 
the  bacterial  causation  so  accidental  that  a  study  of  the 
bacteriology  of  the  dental  abscesses  was  found  a  fruitless 
task,  and  furthermore,  an  undertaking  of  small  practical 
importance,  until  lately,  when  the  process  of  focal  infec- 
tion was  discovered.  The  bacteriological  question,  then, 
becomes  at  once  one  of  first  importance,  if  we  look  at  the 


PLATE      XXVI 


Fig.  115 


Fig.  116 


Fig.   115. — Kadiograph,  showing  granuloma  from  which  the   smear 
below  was  made. 

Fig.  116. — Microphotograph  of  a  smear  taken  from  abscess  seen  in 

Fig.  115.     Note  the  two  chains  of  streptococci  and  groups  of 

staphylococci. 

Specimen  prepared  by  author;  stained  with  methylen  blue. 


BACTERIOLOGY  59 


unfilled  root  canal  containing  remnants  of  diseased  pulp, 
or  the  acute  and  chronic  dental  abscess  and  the  granuloma 
as  a  focus  from  which  not  only  bacteria  may  become  ab- 
sorbed and  distributed  to  other  parts  of  the  body,  but 
where  protein  poisons  (see  Chapter  I)  may  be  generated 
and  taken  up  by  the  circulation,  thus  causing  general 
toxemia  or  local  disease  of  certain  delicate  tissues.  We 
have  already  seen  that  the  protein  poisons  which  are 
formed  during  infection  differ,  among  other  things, 
according  to  the  species  of  the  invading  bacteria  and  it 
is  therefore  desirable  to  know  which  of  the  bacteria  en- 
countered in  these  lesions  produce  secondary  disease, 
either  by  direct  infection  or  by  the  formation  of  patho- 
genic poisons  which  become  absorbed  and  may  cause  auto- 
intoxication similar  to  that  of  intestinal  origin. 

The  study  of  the  bacteria  of  dental  abscesses,  which  was 
first  undertaken  to  find  the  etiological  factor  of  the  local 
lesion,  has  now  become  of  new  importance,  but  from  a 
different  reason,  namely :  that  of  investigating  the  effect 
of  pathogenic  or  saprophytic  bacterial  life  in  a  certain 
part  of  the  body  called  a  focus  such  as  a  root  canal,  ab- 
scesses, or  granuloma  upon  other  parts  of  the  body. 

From  Acute  Abscesses.  Wash  the  mucous 
methods  OF  membrane  thoroughly  with  a  mild  anti- 
bacterial.0  sePtic  mouth  wash  (the  spray  may  be 
specimen  used).  Apply  iodine  on  the  gum,  and  as 
soon  as  the  incision  is  made,  introduce  a 
sterile  pipette  deeply  into  the  abscess  to  collect  the  pus. 
The  pipette  is  then  sealed  and  sent  to  the  laboratory. 
Instead  of  the  pipette  a  sterile  syringe  may  be  used. 

From  Chronic  Abscesses  and  Granulomata  of  Teeth 
which  are  Extracted.  First  of  all  remove  the  tartar  or 
other  deposits  from  the  tooth  and  spray  the  mouth  and 
teeth  with  an  antiseptic  solution,  then  scrub  the  mucous 
membrane  in  the  region  of  the  offending  tooth  as  care- 
fully as  possible.  Pack  sterile  gauze  on  either  side  of 
the  tooth  to  exclude  saliva,  dry  the  mucous  membrane 
with  gauze  and  compressed  air,  and  saturate  tooth  and 
gum  with  tincture  of  iodine.     The  ligamentum  circulare 


60  ORAL  ABSCESSES 


is  then  cut  free  from  the  tooth,  after  which  iodine  is  em- 
ployed a  second  time  to  destroy  bacteria  which  always 
lodge  immediately  under  the  mucous  membrane.  Extract 
the  tooth  and  place  the  forceps  holding  the  tooth  on  a 
piece  of  sterile  gauze,  apex  of  the  tooth  uppermost.  Cu- 
rette with  a  sterile  instrument  the  alveolar  socket  from 
which  the  tooth  was  extracted  to  remove  the  granulations, 
and  smear  some  of  the  removed  tissue  over  the  slant  sur- 
face of  a  culture  tube.  Two  plantings  may  be  made,  one 
for  aerobic,  the  other  for  anaerobic  cultures.  Imme- 
diately after  the  operation  clip  off  the  apex  of  the  removed 
tooth  with  sterile  Rongeur  forceps  and  drop  it  into  an- 
other culture  tube.  It  is  advisable  to  let  it  drop  into  the 
water  of  condensation  and  smear  it  afterwards  over  the 
surface  of  the  media. 

From  Chronic  Abscesses  and  Granulomata  in  Apiec- 
tomy.  As  this  operation  is  performed  under  the  princi- 
ples of  asepsis  no  further  precautions  need  to  be  taken. 
The  amputated  root  is  at  once  dropped  into  a  culture 
tube  held  and  opened  by  an  assistant.  Other  cultures  are 
made  from  the  removed  granulation  tissue. 

Immediate  Microscopic  Examination. 
bacte>rial)F  ^us  gained  from  acute  abscesses  may  be 
STUDY  examined  directly  under  the  microscope 

by  making  the  usual  cover  glass  prepara- 
tions. Also,  from  chronic  condition  may  we  secure  cover 
glass  preparations  by  smearing  the  end  of  the  root  or  a 
piece  of  infectious  granulation  tissue  over  the  cover  glass. 

Inoculation  of  Artificial  Culture  Media.  Specimens 
gained  from  acute  or  chronic  abscesses  by  the  methods 
already  described  may  be  inoculated  on  artificial  media 
for  special  identification,  and  pure  cultures  may  be  made 
of  the  bacteria  which  perhaps  have  already  been  recog- 
nized in  a  general  way  in  a  cover  glass  preparation. 

The  cultures  should  be  grown  on  various  media  and 
both  under  aerobic  and  anaerobic  conditions.  Anaerobic 
bacteria  are  especially  hard  to  cultivate  and  it  is  of  great- 
est importance  to  inoculate  the  media  without  loss  of  time 
so  as  not  to  endanger  the  vitality  of  the  anaerobes. 


BACTEKIOLOGY  61 


Inoculation  of  Animals.  The  animals  which  are  or- 
dinarily used  for  inoculation  are  rabbits,  guinea  pigs,  and 
mice.  Rabbits  and  guinea  pigs  are  usually  inoculated  by 
the  subcutaneous  or  intraperitoneal  method.  A  very 
simple  method  in  rabbits  is  the  intravenous  inoculation. 
The  tip  of  the  ear  is  held  by  thumb  and  fingers  of  the  left 
hand,  while  the  right  manipulates  the  syringe.  The 
needle  is  pushed  through  the  skin  on  the  external  surface 
into  the  posterior  vein  which  runs  along  the  margin  of 
the  ear.  By  the  exercise  of  care  and  gentleness  the  ani- 
mal may  thus  be  inoculated  without  being  anaesthetized 
or  even  held  by  an  assistant,  especially  if  the  fur  between 
its  ears  is  stroked  for  a  short  time. 

Animal  inoculation  is  used  to  find  out  whether  the  bac- 
teria in  question  are  pyogenic  or  not.  The  animal  usually 
dies  of  the  same  disease  that  was  produced  in  man.  If 
bacteria  taken  from  a  questionable  focus  produce  in  the 
animal  the  same  disease  the  patient  suffers  from,  we  can 
conclude  that  we  have  found  the  organism  which  causes 
the  systemic  disease. 

Schreier*  (1893)  gives  in  his  article  the 
the  bacter-  reSTinLs  °f  nine  examined  cases.  In  five 
iological  cases  he  took  his  material  from  the  in- 
study  OF  flamed     periosteum,     involved     by     an 

^!^A_B"  alveolar  abscess,  and  in  four  cases  from 

a  subgingival  parulis.  In  three  cases  he 
found  only  the  diplococcus  pneumoniae,  in  three  cases 
only  the  staphylococcus  pyogenes  albus,  in  the  remaining 
three  cases  he  found  both  the  diplococcus  and  the  staphy- 
lococcus present.  He  concludes  from  this  that  periostitis 
(acute  abscess)  is  due  to  infection  by  pus  producing  bac- 
teria and  especially  to  the  diplococcus  pneumoniae,  which, 
he  adds,  was  also  found  in  two  abscesses  due  to  caries 
examined  by  Nannotti* ;  Miller  and  Sieberth  contest  that 
Schreier 's  diplococcus  is  identical  with  the  diplococcus 
pneumoniae. 

*  See  Bibliography. 


62 

ORAL  ABSCESSES 

SCHREIER   1893 

DlPLOC. 

PNEUMONIAE 

Staphylococ.  p.  albus 

Case  1. 

+ 

Case  2. 

+ 

Case  3. 

+ 

Case  4. 

+ 

Case  5. 

+ 

Case  6. 

+ 

Case  7. 

+ 

+ 

Case  8. 

+ 

+ 

Case  9. 

+ 

+ 

Nannotti  1891 

Case  1. 

+ 

Case  2. 

+ 

Miller*  (1894)  examined  two  cases  of  alveolar  abscesses 
and  found  in  one  two  different  varieties,  in  the  other  one 
variety  of  a  coccus. 

Arkovy*  (1898)  examined  four  cases  of  periostitis 
alveolaris  chronica  diffusa  (chronic  alveolar  abscess,  as  a 
sequel  to  the  acute  alveolar  abscess)  and  found  in  one  case 
the  bacillus  gangraenae  pulpae  alone,  in  two  cases  to- 
gether with  the  staphylococcus  pyogenes  aureus  and 
albus,  and  in  another  case  there  was  no  growth  on  the 
culture  plates. 


Aekovy  1898 

Bac.  gangeenae  pulpae 

Staphylococ.  p. 

AUREUS 

Staphylococ.  p. 

ALBUS 

Case  1. 

+ 

Case  2. 

+ 

+ 

+ 

Case  3. 

+ 

+ 

+ 

Case  4. 

Goadby*  (1903)  pronounces  the  cocci  as  the  bacteria 
found  in  almost  all  the  alveolar  abscesses.  He  examined 
twenty  cases  and  very  often  finds  a  staphylococcus  de- 

*  See  Bibliography. 


BACTEEIOLOGY  63 


scribed  under  the  name  of  staphylococcus  viscosus.  The 
staphylococcus  he  finds  in  half  of  the  cases,  the  staphy- 
lococcus aureus  in  three  cases,  and  sometimes  also  the  mi- 
crococcus tetragenus.  In  two  cases  with  fetid  pus  he 
discovered  the  bacterium  coli  and  in  four  cases  of  diffuse 
alveolar  abscesses  he  grew  besides  the  staphylococcus  al- 
bus  a  constant  anaerobic  bacterium  which  formed  long 
threads  and  produced  much  gas.  When  stained  with 
methylen  blue  it  took  the  color  irregularly.  He  was  not 
able  to  get  a  pure  culture.  This  is  the  first  mention  of 
the  discovery  of  an  obligate  anaerobic  microorganism  in  a 
pathological  process  of  dental  origin. 

Partsch*  (1904)  reports  a  well  observed  case  of 'tuber- 
culosis of  the  jaws  near  the  apex  of  a  root  and  for  the 
first  time  described  the  microscopic  picture  of  a  tuber- 
cular periodontitis. 

Monier*  (1904),  a  Frenchman,  was  the  first  to  make 
a  study  of  the  anaerobic  bacteria  in  connection  with  his 
bacteriological  study  of  six  alveolar  abscesses.     In  Case 

VI,  a  boy  of  the  age  of  nine,  who  was  suffering  with 
" osteo-periostite"  (alveolar  parulis)  caused  by  a  carious 
left  lower  first  molar  he  found  a  micrococcus  and  a  bacil- 
lus by  microscopic  examination  and  gram  stain  of  the 
lightly  fetid  pus.  On  the  surface  of  agar  cultures  fine 
gray  colonies  grew,  which  he  identified  as  streptococci. 
In  the  depth  of  the  agar  cultures  where  there  is  exclusion 
of  air  he  found  longitudinal  and  round  granular  colonies 
which  he  identified  as  the  bacillus  Ramosus.     In   Case 

VII,  a  woman  at  the  hopital  *  Saint- Antoine,  the  follow- 
ing diagnosis  was  made:  Osteo-periostite,  absces  bien 
collects,  overture  (large  alveolar  parulis  with  sinus)  on 
the  left  superior  or  lateral  incisor.  Microscopic  exami- 
nation of  the  very  liquid,  fetid,  grayish  pus  shows  leuco- 
cytes in  the  stage  of  destruction  scarcely  stained.  He 
found  gram  positive  micrococci  of  small  number  and  a 
gram  positive  bacillus;  besides  these  a  gram  negative 
bacillus.  Aerobic  cultures  yielded  a  scarce  growth  of 
streptococci  and  in  anaerobic  cultures  he  found  the  bacil- 

*  See  Bibliography. 


64  OEAL  ABSCESSES 


lus  f  ragilis  in  large  quantity  and  the  bacillus  Ramosus  in 
small  numbers.  Case  VIII  lie  saw  in  consultation  at  the 
"hopital  de  VInstitut  Pasteur"  with  "  Osteo-periostite  du 
maxillaire  inferieur  avec  oedeme  considerable  (alve- 
olar parulis,  with  large  oedematic  swelling)  caused  by  a 
right  lower  bicuspid.  The  abscess  broke  during  the  ex- 
amination ;  he  found  streptococci,  staphylococci  albi,  and 
numerous  anaerobic  bacteria,  among  them  the  bacillus 
Ramosus.  As  the  material  could  not  be  collected  with 
the  necessary  precautions,  the  study  of  this  case  was  not 
further  followed  up.  Case  IX  was  a  patient  who  suf- 
fered from  an  enormous  swelling  in  the  submaxillary 
region,  extending  over  the  whole  cheek,  suborbital  region 
and  subhyoid  region  caused  by  a  tooth  in  the  left  lower 
jaw.  There  was  intense  trismus,  the  skin  was  covered 
with  an  erysipelitic  reddish  color.  During  the  night 
there  was  delirium,  the  swelling  became  fluctuating  in 
the  submaxillary  region  and  an  opening  was  made  with 
thermocautery.  Examination  of  the  horribly  fetid 
pus  showed  partly  destroyed  leucocytes  and  a  veritable 
mixture  of  microorganisms.  He  found  bacilli  of  fine  and 
short  form  often  encapsulated,  V-shaped  bacilli,  cocci  in 
chains,  and  a  rare  bacillus  occurring  in  filaments.  Cul- 
tures yielded  a  streptococcus,  bacillus  Fragilis  and  Ramo- 
sus which  were  most  abundant;  the  other  unnamed  bac- 
teria could  also  be  obtained  in  pure  culture.  Case  X, 
23atient  with  llabsces  volumineux  de  la  voute  palatine" 
(palatal  alveolar  parulis)  from  a  right  upper  incisor 
tooth.  The  pus  which  was  mixed  with  black  blood  showed 
on  microscopic  examination  only  fragments  of  leucocytes 
which  hardly  stained.  The  enormous  quantity  of  bac- 
teria consisted  of  diplococci,  curved  bacilli,  often  of  the 
shape  of  a  V,  which  were  gram  positive,  a  short  and  fine 
bacillus  and  a  rare  bacillus  of  very  large  form,  both  gram 
negative.  Inoculation  on  the  surface  of  agar  yielded  no 
growth  whatever,  but  the  anaerobic  bacteria  were  very 
abundant.  He  isolated  the  bacillus  Fragilis,  the  curved 
bacillus  which  was  identified  as  bacillus  Ramosus  and  the 


See  Bibliography. 


BACTERIOLOGY 


65 


diplococcus  which  was  found  to  be  the  coccus  foetidus. 
The  large  bacillus  which  was  seen  in  small  quantity  grew 
in  large  white,  coarse  cultures  and  was  found  to  be  a 
bacteria  that  had  not  yet  been  described.  This  case  is 
interesting  because  a  large  amount  of  pus  was  produced 
in  this  abscess  without  the  presence  of  any  aerobic  bac- 
teria but  was  due  to  four  anaerobes.  Case  XI,  a  young 
girl  at  the  "hopital  des  Enfants-Malades,"  had  suffered 
with  a  great  deal  of  pain  from  a  left  inferior  first  molar 
for  three  months.  The  abscess  broke  first  into  the  mouth 
and  later  formed  a  sinus  to  the  outside  of  the  face.  Micro- 
scopic examination  of  the  abundant  pus  showed  well 
stained  leucocytes,  and  gram  positive  curved  bacilli  some- 
times occurring  in  chains  of  two.  Surface  cultures 
stayed  sterile  but  in  the  middle,  deprived  of  air,  he  ob- 
tained cultures  of  the  bacillus  Ramosus,  which  was  the 
only  microorganism  found. 


Aerobes 

Anaerobes 

1904 

Strepto- 
cocci 

Strepto- 
cocci 

Diplococci 
foetidus 

B.  Bamosus 

B.  Fragilis 

Undescribed 
bacilli 

Case     VI 

+ 

+ 

Case   VII 

+ 

+ 

+ 

Case  VIII 

+ 

Case     IX 

+ 

+ 

+ 

+ 

Case       X 

+ 

+ 

+ 

+ 

+ 

Case     XI 

+ 

Vincent*  (1905)  writes  in  his  article  "La  symoiose 
fusospirillaire  ses  di  verses  determinations  pathologique" 
that  he  found  seven  times  in  seventeen  cases  of  "suppu- 
ration dentaire  sous  periostique"  (subperiosteal  parulis) 
the  association  of  fuso  spirillae,  once  as  a  pure  infection. 

Mayerhofer*  (1909)  thinks  the  streptococci  are  the  pri- 
mary cause  of  " periostitis  dentalis"  (alveolar  parulis). 
In  examining  twenty-two  cases  of  pus  gained  from  un- 
opened abscesses  and  twenty-eight  cases  of  pus  taken 

*  See  Bibliography. 


66 


OBAL   ABSCESSES 


from  sinuses  on  the  gum,  he  found  thirty  times  strepto- 
cocci in  pure  culture,  fourteen  times  streptococci  and 
bacilli,  twice  streptococci  and  staphylococci,  once  staphy- 
lococci and  bacilli,  twice  stapylococci  alone,  and  once  ba- 
cilli alone.  He  thinks  that  staphylococci  are  perhaps 
present  only  on  account  of  secondary  infection  of  media 
prepared  by  streptococci  and  that  the  bacilli  are  etiolog- 
ically  without  importance.  Apparently  he  made  no 
attempts  to  grow  anaerobes. 


Mayeehofee  1909 

Steeptococci 

Staphylococci 

Bacilli 

30  cases 

+ 

14  cases 

+ 

+ 

2  cases 

+ 

+ 

1  ease 

+ 

+ 

2  cases 

+ 

1  case 

+ 

+ 

Idman*  (1913),  of  the  Pathological  Institute  of  the 
Helsingfors  University  (Finland),  has  written  the  most 
complete  and  thorough  bacteriological  study  of  the  acute 
alveolar  abscess  published  in  the  "Arbeiten  aus  dem 
Pathologischen  Institut  der  Universitat  Helsingfors/' 
His  publication  is  based  upon  most  careful  and  painstak- 
ing research  work,  each  analysis  representing  four  weeks 
of  steady,  tedious  work. 

He  described  his  method  of  obtaining  and  inoculating 
the  culture,  the  preparation  of  the  fourteen  different 
media  used  and  the  staining  methods  for  coverslip  exam- 
ination. 

He  examined  eight  cases  of  undoubted  dental  origin 
which  had  not  undergone  therapeutic  treatment  at  any 
time,  contamination  from  the  fluids  of  the  mouth  was 
carefully  excluded,  and  by  careful  technique,  the  pus  was 
aspirated  by  a  Pravaz  syringe  and  emptied  into  a  sterile 
test  tube.  The  different  media  were  inoculated  as  soon 
as  possible,  never  later  than  an  hour  was  allowed  to  elapse, 

*  See  Bibliography. 


BACTEEIOLOGY  67 


so  as  not  to  endanger  the  vitality  of  the  anaerobes.  The 
oxygen  tolerating  bacteria  were  grown  on  agar  (Titer  15- 
18),  blood  agar  and  glucose  agar  (Titer  15-18).  The  ob- 
ligate anaerobes  were  gained  by  shake  cultures  in  series 
of  10-12  tubes  of  Agar  (Titer  2-3),  10-12  tubes  of  glucose 
agar  (Titer  15-18),  10-12  tubes  of  ascites  glucose  agar 
(Titer  ca.  8)  and  10-12  tubes  of  Indigo-glucose  agar. 
Some  of  the  isolated  bacteria  he  tested  as  to  their  viru- 
lence by  subcutaneous  inoculation  into  rabbits  or  guinea 
pigs,  using  5-10  c.c.  of  a  young  bouillon  culture.  To  study 
the  microorganisms  gained  in  these  cultures  he  used 
gram  stain,  the  polychrom-methylen-blue-tannin  method, 
and  Ziehl's  carbofuchsin  stain. 

Case  A.  A  woman  thirty  years  of  age,  with  subgingival 
parulis,  caused  by  a  suppurating  pulpitis.  The  thick  yel- 
low pus  was  of  neutral  reaction  and  odorless.  Microscopic 
examination  and  cultivation  showed  an  oxygen  tolerant 
streptococcus  and  bacillus  mesentericus  and  obligate 
anaerobes  identified  as  a  streptococcus,  Bacillus  Ramosus 
and  Idman's  bacillus  No.  13. 

Case  B.  A  nineteen  year  old  peasant  boy  presented  a 
subgingival  parulis  from  a  putrescent  pulp.  The  pus 
which  showed  a  slightly  alkaline  reaction,  was  odorless. 
The  bacteria  he  isolated  were  the  oxygen  tolerant  strep- 
tococcus, staphylococcus  albus,  micrococcus  tetragenus 
and  the  elongated  cocci  Idman  No.  6,  the  obligate  ana- 
erobes, bacillus  ramosus.  Case  C  was  a  patient  presenting 
a  subperiostal  parulis  from  a  first  molar.  The  yellowish 
white  pus  was  of  extremely  fetid  odor  and  slightly  alka- 
line. Cultivation  and  isolation  yielded  the  oxygen  tole- 
rant corynebacterium  pseudodiphtheriticum  and  the 
obligate  anaerobic  streptococcus  anaerobicus,  bacillus 
ramosus,  bacillus  thetoides,  bacillus  perfringens.  Case 
D,  a  young  man,  age  seventeen,  with  subperiosteal  pa- 
rulis. Microscopic  examination  of  the  exudates  showed 
an  abundant  bacterial  flora  which  were  cultivated  and 
identified  as  follows:  Oxygen  tolerant;  streptococcus, 
bacillus  Idman*  No.  3,  obligate  anaerobic ;  streptococcus, 


See  Bibliography. 


68 


ORAL   ABSCESSES 


staphylococcus  parvulus,  bacillus  ramosus,  bacillus  the- 
toides,  bacillus  perfringens,  bacillus  bifidus  communis 
and  bacillus  Idman  No.  14.  Case  E,  also  a  case  of  subper- 
iosteal parulis  with  thick  yellowish  pus  without  odor  nor 
reaction  yielded  the  oxygen  tolerant  bacillus  Idman  No.  3 
and  the  obligate  anaerobe  bacillus  ramosus.  Case  F,  a 
case  of  subperiosteal  abscess,  contained  thin  pus  of 
strongly  alkaline  reaction.  The  following  bacteria  were 
found :  oxygen  tolerant ;  streptococcus,  obligate  anaerobe ; 
staphylococcus  iungano,  staphylococcus  parvulus,  bacil- 
lus thetoides,  bacillus  ramosus  and  bacillus  fusiformis. 
Case  G,  a  subgingival  abscess  with  grayish  white  pus  of 
neutral  reaction,  contained  large  oxygen  tolerant  cocci 
single,  double  and  in  packs,  (staphylococci)  also  small 
oxygen  tolerant  streptococci.  The  obligate  anaerobes 
were  found  to  be  streptococci  and  the  bacillus  ramosus. 
Case  H,  a  subgingival  abscess,  was  not  fully  completed. 
It  contained  oxygen  tolerant  staphylococci  and  the  ba- 
cillus ramosus. 


Oxygen  Tolerant 

Obligate  Anaerobic. 

Idman 
1913 

"3 
« 
o 
<a 
o 

<x> 
u 
-4J 

m 

o 
o 
o 

o 

T> 
A 

ft. 
eS 

w 

o 
o 
o 

ft 

CO 

fl 

CD 
bD 
c3 
M 

CD 

+3 

o 
o 
o 

M 

w 

% 

co 

=s 
o 

•  r* 

H 

ai 

ft 

CD 
to 
a> 

a 
ri 

'u 
CD 
A 

ft 
O 

9 
CO 

ft 

ri 

•  iH 

"3 
O 

"3 

<a 
o 
o 
o 

Ph 
CD 
Sh 

02 

02 

> 

J-l 

An 

d 
o 

S3 
O 

T» 

ft 
c3 
+i 
02 

o 

bo 

s 

1— 1 

d 
O 

o 
o 

"?» 

cS 

02 

EC 

1=1 
00 

o 

1 

u 
ffl 

CO 
CD 

12 
'3 

CD 

ri 

CO 

Pi 

CD 

.5 

fH 

CD 

Ph 

ri 

CO 

a 

o 
"to 

ri 

CO 

=s 

S 

a 

o 
o 

to 

Pj 

ri 

«rH 

o 
c$ 
,Q 

CD 

r=3 

-^> 

o 

Case    A 

+ 

+ 

+ 

+ 

+ 

Case    B 

+ 

+ 

+ 

+ 

+ 

Case     C 

+ 

+ 

+ 

+ 

+ 

Case    D 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

Case    E 

+ 

+ 

Case    F 

+ 

+ 

+ 

+ 

+ 

+ 

Case    G 

+ 

+ 

+ 

+ 

Case    H 

+ 

+ 

PLATE     XXVII 


Fig.  117 


Fig.  118 


Fig.  117. — Eadiograph  of  a  tooth  with  large  granuloma  which  proved 
to  contain  colonies  of  actinomyces. 

Fig.    118. — Microphotograph    of    a    section    of    the    above    granuloma. 

Specimen  prepared  by  author;  stained  with  methylen  blue  and  Eosin. 


BACTERIOLOGY  69 


The  animal  experiments  undertaken  with  these  bacteria 
he  reported  under  a  special  head,  describing  the  isolated 
microorganisms. 

Bacillus  pseudodiphtheriticum  (aerobic)  was  injected 
into  guinea  pigs  in  the  form  of  a  5  c.c.  of  a  22-hour  old 
bouillon  culture.  There  was  an  increased  temperature 
on  the  second  day,  no  other  pathological  conditions. 

Aerobic  streptococci,  two  of  which  form  no  haemolysis, 
two  others  cause  a  very  weak  haemolytic  phenomenon, 
were  not  all  used  for  animal  experiments.  One  strain  of 
the  latter  was  injected  subcutaneously  into  a  rabbit  and 
caused  only  temporary  decrease  of  weight,  but  no  other 
pathologic  conditions. 

Bacillus  ramosus  (anaerobic)  was  tested  on  rabbits. 
Five  of  the  isolated  strains  were  used,  two  immediately 
after  the  isolation.  Ten  c.c.  of  a  three  to  seven  days'  cul- 
ture was  injected  subcutaneously.  None  produced  an  ab- 
scess at  the  place  of  inoculation.  In  each  case  he  ob- 
served a  slow  decrease  in  weight  lasting  from  two  to  three 
weeks.  Only  one  case  resulted  in  death  of  the  animal 
after  thirty-three  days ;  in  all  the  other  cases  the  animal 
slowly  recovered. 

Bacillus  perfringens  (anaerobic)  proved  pathogenic 
for  guinea  pigs.  After  injection  of  3  c.c.  of  a  fresh 
bouillon  culture  an  extensive  local  infiltration  occurred 
which  showed,  when  cut,  a  foamy  oedematic  secretion  re- 
sembling saliva  which  contained  the  bacteria  in  pure 
culture.  With  one  strain  experiments  were  made  to  in- 
crease the  virulence,  which  was  successful  after  passage 
through  two  guinea  pigs.  The  third  animal  died  inside 
of  thirty-six  hours  after  injection  of  3  c.c.  of  a  fresh 
bouillon  culture.  Culture  from  the  heart  blood  gave  a 
positive  result. 

Bacillus  bifidus  communis  (anaerobic)  caused  no  path- 
ogenic effects  in  rabbits  from  injection  of  10  c.c.  of  a 
bouillon  culture. 

Bacillus  thetoides  (anaerobic)  was  used  only  in  one 
strain  for  animal  experiments.     The  weight  of  the  rab- 


70  ORAL   ABSCESSES 


bits  decreased  slowly  for  one  week,  after  which  they 
recovered.  Only  on  the  second  day  there  was  an  increase 
in  temperature. 

Streptococci  anaerobic,  no  animal  experiments. 

Staphylococcus  parvulus  caused  no  pathologic  con- 
ditions in  rabbits. 

Staphylococcus  iungano  caused  no  pathologic  con- 
ditions after  injections  of  10  c.c  of  a  bouillon  culture. 

In  regard  to  these  animal  experiments,  it  must  be 
remembered,  when  compared  with  the  results  of  Hartzel- 
Henrici,  that  the  organs  of  these  inoculated  animals  had 
apparently  not  been  examined  pathologically,  and  that  the 
pathogenicity  of  the  bacteria  was  only  judged  from  local 
effects  and  as  to  the  life  or  death  of  the  animal.  Hartzel- 
Henrici  observed  the  low  virulence  of  streptococci  infec- 
tions when  injected  into  animals,  producing  death  only 
after  a  long  period  if  at  all,  although  there  were  serious 
lesions  developing  in  some  of  their  important  organs 
which  can  only  be  demonstrated  in  microscopic  sections 
of  the  diseased  parts. 

Gilmer*  (1914) .  Gilmer,  who  reports  bacterial  exami- 
nations of  acute  and  chronic  abscesses,  in  a  general  way, 
found  streptococci  in  aerobic  cultures,  and  occasionally 
the  staphylococcus  albus  and  aureus,  and  the  micrococcus 
catarrhalis.  In  anaerobic  cultures  he  found  streptococci 
and  the  bacillus  fusif ormis  either  alone  or  in  mixtures,  as 
well  as  a  black  pigment-forming  organism  which  usually 
did  not  appear  for  about  five  days. 

Thoma*  (1915).  The  author  reported  in  a  paper  read 
before  the  American  Academy  of  Dental  Science  his  re- 
sults of  cultures  taken  since  November,  1914,  of  all 
abscessed  teeth  in  the  hospitals  as  well  as  in  his  private 
practice.  He  concludes  that  any  microbes  belonging  to 
the  flora  of  the  oral  cavity  may  be  found  in  oral  abscesses. 
Streptococci  which  grew  aerobically  and  anaerobically 
were  found  in  the  majority  of  cases,  sometimes  as  pure 

*  See  Bibliography. 


PLATE     XXVIII 


Fig.  119. 

Microphotograph  of  a  section  of  a  granuloma  containing  colonies  of 

actinomyces. 
Specimen  prepared  by  the  author  and  stained  by  the  Gram-Weigert  Method. 


BACTERIOLOGY  71 


cultures,  but  frequently  mixed  with  staphylococcus  albus 
and  aureus.  Besides  these  he  often  found  an  admixture 
of  many  other  pathogenic  and  saprophytic  bacteria  such 
as  the  bacillus  fusiformis,  bacillus  coli,  the  influenza 
bacillus,  and  the  bacillus  proteus. 

In  two  cases  he  found  the  fungus  of  actinomycosis. 
This  organism  has  been  demonstrated  several  times  in 
root  canals  by  Partsch*  and  was  found  by  the  author  in 
a  large  granuloma  of  an  upper  lateral  incisor,  and  in  the 
root  canal  as  well  as  in  a  granuloma  of  a  lower  bicuspid 
of  another  patient.  Both  men  were  city  people,  there 
were  no  clinical  symptoms  of  general  actinomycosis  of  the 
jaws  of  soft  tissue,  which  is  due  to  the  fibrous  encapsula- 
tion of  the  lesion.  The  first  granuloma  was  removed,  by 
the  regular  method  of  thorough  curettage  used  by  the 
author,  the  character  of  the  abscess  was  not  discovered 
until  later  when  the  specimen,  a  part  of  the  granuloma, 
was  examined.  There  was  no  recurrence  of  the  disease. 
The  other  granuloma  was  adhering  to  the  tooth  and  the 
fungus  of  actinomycosis  was  found  when  the  specimen 
was  prepared.  In  order  to  verify  the  findings  different 
stains  were  used,  the  colonies  in  the  form  of  rosettes  with 
club-shaped  radiating  filaments  were  clearly  visible,  as 
seen  in  Figure  118  and  Figure  119. 

Hartzel  and  Henrici*  (1913, 1914  and  1915) .  The  mouth 
infection  research  corps  of  the  National  Dental  Associa- 
ciation,  consisting  of  Thomas  B.  Hartzel,  Henrici  and 
Leonard,  started  in  September,  1913,  a  closer  study  of 
1  'the  relationship  growing  out  of  the  transplantation  of 
the  chronic  mouth  infections  to  other  parts  of  the  body 
and  a  study  of  the  areas  of  inflammation  in  the  human 
and  animal  body  which  have  been  induced  by  these  trans- 
planted organisms."  They  were  the  first  who  undertook 
to  study  systemically  the  bacteria  found  in  the 
dental  abscesses  in  regard  to  their  systemic  effects 
rather  than  as  to  their  etiological  local  importance.  Their 

*  See  Bibliography. 


72  ORAL   ABSCESSES 


bacteriological  research  work  has  sought  to  determine  by 
animal  inoculation  the  character  of  the  damage  wrought 
in  the  various  organs  of  the  body  by  the  introduction  of 
intravenous  injections  of  living  organisms  cultivated 
from  lesions  in  the  mouths  of  the  patients  studied.  The 
bacteriological  study  reported  October,  1914,  and 
November,  1915,  in  the  Journal  of  the  National  Dental 
Association  alone  represents  an  enormous  amount  of 
work  and  the  conclusions  drawn  from  the  pathological 
study  of  the  animal  experiments  mark  a  classic  epoch  in 
the  study  of  dentistry. 

The  first  report  is  based  upon  a  study  of  eighty-two 
cases,  the  second  report  was  published  after  about  two 
hundred  additional  cases  of  chronic  periodontal  infections 
had  been  bacteriologically  examined.  Attention  was 
from  two  reasons  directed  almost  solely  to  the  strepto- 
cocci, first  because  they  were  constantly  present  and  fre- 
quently were  the  sole  cultivable  organisms  obtained,  and 
secondly,  because  the  research  workers  made  the  relation- 
ship of  dental  infections  to  rheumatism  their  immediate 
problem.  They  however  also  obtained  the  staphylococ- 
cus albus,  the  bacillus  coli,  the  bacillus  proteus,  the 
bacillus  florescens  non-liquefaciens  and  the  pneumo- 
coccus.  Aerobic  as  well  as  anaerobic  cultures  yielded 
the  same  results.  Cultures  made  from  healthy  teeth  have 
constantly  been  found  sterile.  The  cultural  features  of 
the  streptococci  of  these  dental  lesions  then  received  the 
writer's  attention.  On  blood  agar  two  kinds  of  colonies 
were  obtained:  " green"  colonies,  which  produced  a  green 
halo,  and  gray  colonies  without  halo.  With  regard  to 
sugar  fermentation  reactions  for  an  indicator,  for  which 
a  beef  serum  with  one  per  cent,  of  the  various  sugars 
added  had  been  used  with  acid  fuchsin  decolorized  by 
potassium  hydroxide,  they  found  that  the  majority  of 
cases  ferment  either  ramnose  (streptococcus  salivarius) 
or  salicin  (streptococcus  mitis).  Only  in  one  case  had  a 
manite  fermenter  been  observed  (streptococcus  fecalis). 


PLATE     XXIX 


_  5  ■Zme^&t 


v:. 


J^       •<». 


■*f 


'^t^r  l 


-^*«^  '  / '  <? 


>-'-£**;>•' 


^»;i*£*j 


Figure   120. 
Chronic  myocarditis.     The   section   shows  the   heart  muscle   of  a   rabbit  which  died   16 
days  after  an   injection   of  streptococci   from  case   No.   55.     The  section   shows   an   area    of 
fibrosis  with  several  giant  cells. 


Figure   121 
Acute  myocarditis.     Section  of  heart  muscle  from  a   rabbit  which  died   48  hours  after 
an  injection  of  streptococci   from  case  No.   60.     The  section  shows   an  area   of  lympholdal 
infiltration. 

Both  illustrations  reproduced  by  courtesy  of  Dr.  Hartzel. 


BACTERIOLOGY 


73 


TABLE  OF  FERMENTATION  OF  STREPTOCOCCI  FROM  CHRONIC 
DENTAL  LESIONS 


d 

pa 

<j 
o 
< 

a 
o 
o 
►J 
pq 

M 

co 

p 

a  ■ 

E-i 

H 
to 

O 

H 
D 

< 

CO 
O 
« 

< 
W 
o 
o 

< 
w. 

< 

CO 

o 

< 

g 

< 

H 

110 

Green 

Acid,  Coag. 

Acid 

0 

0 

0 

Acid 

0 

116 

Green 

0 

Acid 

Acid 

0 

0 

Acid 

0 

121 

Green 

0 

Acid 

Acid 

0 

0 

Acid 

0 

122 

Green 

Aeid 

Acid 

Acid 

0 

Acid 

Acid 

0 

123 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

Acid 

Acid 

0 

124 

Green 

Acid 

Acid 

Acid 

0 

Acid 

Acid 

0 

125 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

Aeid 

0 

0 

127 

Green 

Acid,  Coag. 

0 

Acid 

0 

0 

Acid 

0 

129 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

Acid 

Acid 

0 

130 

Green 

Acid,  Coag. 

Acid 

0 

0 

0 

Acid 

0 

133 

Green 

Acid,  Coag. 

Aeid 

Acid 

0 

Acid 

0 

0 

134 

Green 

Acid,  Coag. 

Acid 

Acid 

Acid 

0 

Acid 

0 

135M 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

Acid 

0 

0 

135B 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

Acid 

Acid 

0 

136 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

0 

0 

0 

137 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

0 

Acid 

0 

138 

Green 

Acid 

Acid 

Acid 

0 

0 

Acid 

0 

141 

Green 

0 

0 

Acid 

0 

0 

0 

0 

20 

Green 

Acid 

0 

Acid 

0 

0 

0 

0 

21 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

0 

0 

0 

23 

Green 

Acid 

Acid 

Acid 

0 

0 

0 

0 

27 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

Acid 

0 

0 

28 

Green 

Aeid,  Coag. 

0 

Acid 

0 

Acid 

Acid 

0 

29 

Green 

Acid 

Acid 

Acid 

0 

0 

0 

0 

32 

Green 

Acid 

Aeid 

Acid 

0 

Acid 

Acid 

0 

34 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

0 

0 

0 

35 

Green 

Acid,  Coag. 

Acid 

Acid 

0 

Acid 

0 

0 

36 

Green 

Acid 

Acid 

Acid 

0 

Acid 

Acid 

0 

Two  facts  stand  out  prominently  from  their  work: 
members  of  the  streptococcus  viridans  group  are  con- 
stantly present  in  chronic  dental  infections,  especially  the 
streptococcus  salivarius  and  the  streptococcus  mitis,  and 
the  common  pus-producing  haemolytic  streptococci  are 
constantly  absent. 

In  their  animal  experiments  they  used  rabbits  exclu- 
sively, being  more  susceptible  to  streptococci  than  other 
laboratory  animals.  In  their  first  article  they  describe 
seven  animal  experiments  from  cases  which  they  selected 


74  ORAL  ABSCESSES 


for  special  research  study  out  of  one  hundred  examined 
patients.  In  the  second  article  they  mention  that  they 
had  inoculated  two  hundred  and  twelve  additional  rabbits 
with  twenty-two  different  strains  of  streptococci.  From 
these  inoculations  they  are  impressed  by  the  compara- 
tively low  virulence  of  these  streptococci,  though  in  the 
end  the  damage  wrought  by  them  in  the  animal  economy 
was  serious  and  in  some  instances  irreparable.  Some  of 
the  animals  did  not  die  at  all,  and  most  died  a  relatively 
long  time  after  the  inoculation.  Of  the  animals  that  died, 
the  most  striking  features  were  a  progressive  emaciation 
and  loss  of  strength.  The  lesions  produced  in  the  ani- 
mals were  of  diverse  character  occurring  in  the  arteries, 
joints,  kidneys  and  heart.  The  most  common  lesions 
produced  were  those  frequently  associated  with  rheu- 
matism, namely,  myocarditis,  consisting  either  of  diffuse 
infiltration  of  lymphocytes  in  submaxillary  nodules  com- 
posed of  aggregations  of  lymphocytes  or  in  areas  of 
fibrosis  with  occasional  giant  cells.  The  kidneys  were 
frequently  also  the  seat  of  disease,  consisting  of  abscesses 
which  contained  either  polymorphonuclear  leucocytes 
alone  or  associated  with  lymphocytes,  and  which  in  some 
cases  contained  bacterial  emboli,  or  small  aggregations  of 
lymphocytes  along  radial  vessels  of  the  medulla.  The 
arterial  lesions  which  occurred  occasionally  were  destruc- 
tive lesions  of  the  tunica  media  of  the  aorta  in  the  ascend- 
ing portion  of  the  arch  with  a  hypertrophy  of  the  under- 
lying intima. 

The  hearts,  kidneys  and  large  vessels  of  sixteen  healthy 
rabbits  were  also  examined ;  no  lesions  could  be  found. 

The  added  illustrations  have  been  kindly  sent  to  me  by 
Dr.  Hartzel  to  illustrate  this  splendid  work  of  his  re- 
search corps,  and  I  here  take  one  more  especial  occasion 
to  express  my  appreciation  of  his  courtesy,  which  I  feel 
sure  will  also  be  greatly  appreciated  by  the  interested 
reader,  and  induce  him  to  study  in  detail  the  important 
investigations  published  by  Dr.  Hartzel  and  his  asso- 
ciates in  the  various  dental  and  medical  magazines. 


PLATE     XXX 


rsr 


Figure    122 
The    section    shows    an    area    of   wide    spread    infiltration    with    lymphocytes    and   poly- 
morphonuclear leukocytes  in  the  kidney  of  a  rabbit  which  died  48  hours  after  an  injection 
of    streptococci    from    case    No.    59.      This    was    the    second    passage    of    this    streptococcus 
through  rabbits. 


:*»-''fc. 


Figure   123 
This  plate  shows  a  localized  polymorphonuclear  abscess  in  the  medulla   of  the   kidnej 
of  a  rabbit  which  died  48  hours  after  an  injection  of  streptococci  from  case  No.  60. 

Both  illustrations  reproduced  by  courtesy  of  Dr.  Hartzel. 


BACTERIOLOGY  75 


Author's  Remark. — The  investigations  of  Hartzel  and 
other  scientists  give  the  reader  the  impression  that  the 
streptococcus  is  the  only  bacteria  of  the  flora  found  in 
oral  abscesses,  which  should  be  seriously  considered,  and 
that  other  bacteria  may  be  looked  at,  either  as  contamina- 
tion or  organisms  whose  activity  is  restricted  to  the  local 
lesion.  Medical  writers  also,  Rosenow  particularly, 
whose  research  work  has  almost  revolutionized  the  etio- 
logical theories  about  certain  systemic  infectious  diseases, 
considers  the  streptococcus-pneumococcus  group  as  the 
causative  factor  of  secondary  lesions,  caused  by  transpor- 
tation from  the  focus  through  the  blood  stream.  Amongst 
the  large  number  of  bacteria  which  may  be  found  in  oral 
abscesses,  there  are  without  doubt  others  which  may  be- 
come absorbed  and  cause  secondary  disease  or  which 
produce  toxins,  which  when  taken  into  the  circulation 
may  affect  certain  tissues  and  lower  the  health  of  the 
patient.  One  of  the  most  commonly  found  bacteria, 
besides  the  streptococci  is  the  staphylococcus.  It  may  be 
often  found  alone  or  together  with  others.  Dr.  Stein- 
harter  has  very  recently  undertaken  bacteria  experiments 
with  this  organism.  While  the  organisms  had  not  been 
taken  from  oral  abscesses,  I  shall  nevertheless  add  an 
abstract  of  his  experiments,  so  as  to  show  that  other  bac- 
teria than  the  streptococcus  group  should  be  considered 
dangerous  to  the  rest  of  the  body. 

Steinharter*  1916.  The  author  published  two  articles, 
the  first  on  gastric  ulcers,  the  second  on  experimental  pro- 
duction of  acute  arthritis  by  inoculating  animals  with 
staphylococcus  cultures.  Gastric  ulcers  were  produced  by 
injecting  an  emulsion  from  the  agar  growth  (prepared 
by  suspending  a  twenty-four-hour  old  culture  on  agar 
slant  in  10  c.c.  normal  saline)  or  from  the  broth  (by  sus- 
pending in  15  c.c.  of  saline  the  centrifugal  sediment  of  a 
twenty-four-hour  old  150  c.c.  broth  growth).  One  quar- 
ter to  1  c.c.  of  the  emulsion  was  injected  with  1  c.c.  of  a 
weak  acetic  acid  solution.  Forty  rabbits  were  used  for 
the  experiments,  the  hypodermic  injections  were  preceded 

*  See  Bibliography. 


76  ORAL   ABSCESSES 


by  a  laparotomy,  and  the  post-mortems  revealed,  if  or- 
ganisms of  special  virulence  were  used  (for  instance,  one 
freshly  isolated  from  the  appendix)  invariably  typical 
peptic  ulcers  from  one  quarter  of  an  inch  to  one  inch  in 
diameter. 

Acute  arthritis  was  experimentally  produced  by  inject- 
ing intravenously  an  emulsion,  prepared  by  suspending 
an  agar  slant  culture  in  about  10  c.c.  of  normal  saline. 
The  dose  used  was  usually  1  c.c.  for  a  rabbit  and  3  c.c. 
for  a  dog.  It  was  found  that  the  staphylococcus  is  apt  to 
localize  in  the  joints  and  produce  typical  lesions  of  arth- 
ritis, if  the  strain  is  of  proper  virulence,  having  a  prede- 
liction  for  this  region  (staphylococci  from  joints  for 
example  have  a  decided  tendency  to  again  localize  in 
joints)  or  if  the  tissue  in  which  the  organisms  have  lodged 
is  suitably  altered  for  their  growth  and  action. 

The  writer  concludes  that  the  staphylococcus  may  be 
caused  very  regularly  to  localize  in  the  stomach  after 
intravenous  injection.  It  appears  that  the  same  organ- 
ism may  be  caused  to  localize  in  joints  and  produce  typical 
arthritis.  The  published  protocols  show  that  in  some 
cases  arthritis  was  the  only  lesion  found  at  autopsy  but  in 
other  cases  it  was  associated  with  one  or  more  other 
lesions,  namely  duodenal  ulcer,  appendicitis,  cholecystitis, 
myocarditis,  pericarditis,  endocarditis,  nephritis,  colitis 
and  myositis. 


PLATE     XXX 


Fig.  124. — Microphotograph  of  the  end  of  a  tooth  with  an  epitheliated  granuloma. 

A — Lumen.         B — Proliferating   epithelium.         C — Cholesterine   spaces. 
D — Capsule  of  the  granuloma.       E — Blood  vessel.       F — Exostosed  root  end. 

G — Root  canal. 
Stained  with  Mallory's  connective  tissue  stain.     Specimen  prepared  by  the  author. 


CHAPTER  VII 


HISTOLOGICAL    PATHOLOGY 

The  microscopic  study  of  abnormal  conditions  and  dis- 
ease is  not  only  of  great  interest  to  the  pathologist,  but 
of  far-reaching  importance  for  the  understanding  of  the 
beginning,  progress  and  termination  of  disease,  as  well 
as  of  greatest  value  for  the  development  of  the  knowledge 
which  furnishes  the  best  foundation  upon  which  intelli- 
gent treatment,  be  it  of  medicinal  or  surgical  character, 
may  be  based. 

The  infection  of  the  periapical  tissue  of 
pfrio"-  a  tooth  is  transmitted  through  the  apical 

dontitis  foramina   from   the   diseased   pulp    and 

causes,  if  the  amount  and  virulence  of  the 
injurious  agent  is  right,  what  is  clinically  termed  as  acute 
inflammation  of  the  periodontal  membrane,  or  acute  peri- 
odontitis. The  reaction  consists  of  circulatory  disturb- 
ances and  inflammatory  exudation.  The  blood  vessels, 
after  an  initial  constriction,  become  dilated  almost  to 
twice  their  size  and  leucocytes  accumulate  along  their 
walls.  A  serous  infiltration  with  emigration  of  poly- 
morphonuclear leucocytes  occurs  which  is  seen  in  spaces 
formed  between  the  fibres  of  the  periodontal  membrane. 
This  causes  an  increase  in  size  of  the  membrane,  pushing 
the  tooth  out  of  its  socket  and  gives  the  impression  of  an 
elongated  tooth.  If  the  condition  continues,  tissue  de- 
struction sets  in  and  we  find  small  necrotic  areas.  This 
process  is  most  marked  near  the  apical  foramina  from 
where  the  suppuration  spreads. 

acute  After  a  comparatively  short  time  the  pus 

alveolar         kas  co^ec^e(i  m  larger  quantity  and  the 
abscess  bone  forming  the  alveolar  socket  becomes 

involved.  The  fibres  of  the  periodontal 
membrane  still  persist,  become  elongated,  and  parts  of 
bone  are  absorbed.    While  the  bone  is  destroyed  the  pus 


78  ORAL  ABSCESSES 


cavity  enlarges  and  is  called  an  acute  alveolar  abscess.  If 
suppuration  is  very  active  and  prolonged  we  find  destruc- 
tion of  the  fibres  of  the  periodontal  membrane  at  the 
apical  part  as  well  as  involvement  of  the  cementum  of 
the  tooth  which  shows  a  necrotic  appearance  and  has  been 
observed  to  result  in  loss  of  more  than  half  of  the  root 
of  the  tooth. 

After  the  destruction  of  the  lamella  of  the 
alveolar  alveolar  socket  the  cancellous  part  of  the 
parulis  bone  is  freely  infiltrated  with  pus.    The 

Haversian  canals  are  next  involved  by 
means  of  which  the  pus  finds  its  way  through  the  outer 
cortical  layer  of  the  bone.  The  periosteal  tissue  reacts 
at  once  causing  a  local  infiltration  of  polymorphonuclear 
leucocytes  and  a  widespread  serous  infiltration  causing 
large  oedematic  swellings  in  the  cheek  and  neck.  The 
pus  forms  first  under  the  periosteum  (subperiosteal  paru- 
lis) which  presents  a  remarkable  resistance  to  the  destruc- 
tive processes  of  inflammation.  After  the  periosteum  has 
been  penetrated,  necrosis  continues  in  the  submucosa  of 
the  gum  until  it  extends  to  its  surface  and  forms  a  fistula 
which  gives  exit  to  the  accumulated  pus. 

After  the  process  of  destruction  has 
alveol'ar  reached  its  climax,  nature  makes  an  at- 
abscess  tempt  of  healing  by  the  formation  of 

granulation  tissue.  The  necrosed  cells  are 
dissolved  by  the  leucocytes  and  either  absorbed  or  expelled 
through  the  sinus.  Fibroblasts  and  vascular  endothelium 
are  formed  by  proliferation  to  replace  the  necrosed  tissue  ; 
destroyed  cells  and  serous  or  purulent  exudation  from 
remaining  injurious  agents  may  continue  to  pass  through 
the  newly-formed  tissue  to  the  surface.  Endothelial  leu- 
cocytes and  lymphocytes  may  collect  in  large  numbers  in 
the  deeper  layers  of  the  granulation  tissue  to  counteract 
the  irritating  agents  absorbed  from  the  exudates.  This 
condition  clinically  called  chronic  abscess  may  last  for  an 
unlimited  period,  the  discharge  from  the  fistula  may  in- 
crease at  times,  if  the  process  of  destruction  becomes 
more  marked,  or  may  become  less  or  even  stop  entirely 


PLATE    XXXI 


Fig.  125 


Fig.  126 


Fig.  127 


Fig.   128 


FIG.    125. — Microphotograph   of  a  simple  granuloma.      Part    of  the   pulp   lias   been    left    in  the 
root    canal   and   the    granulation   tissue    is    seen   to   extend    from    the    root    canal    through    the 

apical   foramen.      The   blue    spot   shows    a    necrosed  area    in    the    dentine. 
Fig.   126. — Microphotograph  of   a   simple  granuloma     showing    a     distinct     capsule.      There     is 

necrosis    of    the    root    and    a    lateral    lumen. 
FIG.    127. — Microphotograph  of   a   simple  granuloma,    showing   capsule  and  three  places   where 

active   pus   formation   is   going  on. 
FIG.    128. — Microphotograph   of   a    granuloma   with    sinus    in    which    pus    formation    has   taken 

place. 
All  four  specimens  were  prepared  by  the  author,  and    stained    by    Mallory's    Phosphotungslic 

acid,   Hematoxylin  stain. 


HISTOLOGICAL  PATHOLOGY  79 

for  a  certain  period,  a  condition  which  is  usually  only  tem- 
porary but  frequently  brings  about  the  closure  of  the 
mouth  of  the  fistula.  This  will  reopen  with  more  or  less 
marked  subacute  symptoms  as  soon  as  the  suppurating 
process  has  overcome  the  defense  of  the  body,  the  process 
of  repair.  This  picture  should  impress  the  importance 
of  removing  the  cause,  viz.,  a  diseased  dental  pulp  or  the 
necrotic  end  of  the  root  of  the  guilty  tooth.  Perfect 
repair  is  not  possible  as  long  as  a  necrotic  root  apex 
persists. 

In  contrast  to  the  processes  of  suppura- 
proliferat-    tion  of  the  periodontal  membrane  stands 

dontitts  ^e    mucn   more    common    proliferating 

periodontitis  and  its  sequels.  This  is  a 
reaction  to  mild  injurious  agents  such  as  bacteria  in  small 
numbers  and  of  low  virulence,  of  which  the  streptococcus 
mitis  and  salivarius  are  good  examples  and  commonly 
found  in  these  lesions.  But  also  mild  toxins  or  diluted 
stronger  toxins  as  well  as  chemicals  such  as  irritating 
drugs  (formaldehyde)  sealed  in  the  root  canal  cause 
irritation  of  the  periodontal  membrane.  The  reaction 
occurs  first  near  the  apical  foramina  consisting  in  a  focal 
accumulation  of  lymphocytes,  an  increase  in  cells  and 
vessels  and  formation  of  plasma  cells.  Endothelial  leu- 
cocytes and  polymorphonuclear  leucocytes  may  be  more 
or  less  abundant  according  to  the  irritating  agent  causing 
the  inflammation. 

The  dental  granuloma  is  the  sequel  of  the 
granuloma  proliferating  periodontitis.  Its  histo- 
logical study  is  extremely  interesting. 
The  author  has  prepared  microscopic  specimens  of  about 
fifty  of  these  lesions  in  the  research  laboratory  of  the 
Harvard  Dental  School  and  the  following  descriptions 
are  principally  based  upon  original  investigations : 

Simple  granuloma.  The  new  formed  tissue  gains 
in  size  until  it  has  the  microscopic  appearance  of  a  red- 
dish sack  which  reaches  generally  the  size  of  a  large  pea, 
but  occasionally  attains  much  larger  dimensions.  The 
pressure  from  the  growing  lesion  causes  resorption  of  the 


80  ORAL  ABSCESSES 


bone  and  on  microscopic  examination  we  find  that  the 
granuloma  is  surrounded  by  a  fibrous  capsule  which  ex- 
tends between  the  trabeculae  of  the  bone.     The  fibres  of 
the  encapsulating  layer  originate  from  the  periodontal 
membrane,  which  in  some  cases  may  become  detached 
from  the  cementum  of  the  apex,  the  tooth  remaining  in 
others  in  a  more  or  less  modified  way.     The  communica- 
tions with  the  root  canal  usually  persist,  the  granulation 
tissue  seems  to  be  continuous  with  remnants  of  pulp  left 
in  the  apical  part  of  the  root  canal,  while  at  other  times 
the  granulation  tissue  grows  into  the  root  canal.      The 
connection  between  the  periodontal  membrane  and  the 
peripheral  fibrous  capsule  is  often  so  strong  that  the 
granuloma  is  removed  attached  to  the  tooth  in  extraction. 
In  the  majority  of  cases,  however,  we  find  that  the  granu- 
loma remains  in  the  jaws.     The  thickness  of  the  capsule 
varies  greatly  and  contains  fibres,  groups  of  which  grow 
in  various  directions.     This  fibrous  capsule  is  well  illus- 
trated   in    the    microphotographs,     Figures    126    and 
127,  and  in  the  high-power  drawing,  Figure  129,  stained 
by       Mallory's       Phosphotungstic-acid       Hematoxylin 
method.    Vessels  and  capillaries  can  be  seen  in  all  these 
illustrations  of  the  fibrous  capsule,  they  are  usually  sur- 
rounded by  an  increased  number  of  plasma  cells  and  a 
small  number  of  leucocytes ;  their  lumen  is  often  greatly 
increased,  and  the  endothelial  cells  often  show  a  prolifera- 
ting appearance.     Red  corpuscles  are  found  in  the  ves- 
sels together  with  polymorphonuclear  leucocytes  and  a 
granular  substance.     Such  a  vessel  and  capillaries  as  well 
as  fibroblasts  and  infiltrated  cells  are  especially  well  re- 
produced in  Figure  130,  an  oil  immersion  drawing  of  a 
part  of  the  capsule  in  a  section  stained  with  hematoxylin 
and   eosin.      These   studies   impress   the  great  attempt 
which  nature  made  to  wall  off  the  seat  of  inflammation  to 
prevent  spreading  into  the  neighboring  parts.    It,  how- 
ever, also  demonstrates  that  this  capsule  does  not  prevent 
absorption  as  it  contains  a  meshwork  of  capillaries  and  is 
penetrated  abundantly  by  larger  vessels  and  therefore 
its  contents  are  in  direct  communication  with  the  circu- 


PLATE     XXXIII 


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A 

Fig.  129 


G 

Fig.  130 

Fig.    129. — Lithograph    of    high-power    drawing    showing    the    construction    of    the    capsule    of    the 

granuloma    shown   in   Fig.    127. 

A — Blood  vessels  extending  through  the  capsule.        B — Inner  part  of  the  granuloma. 

C — Connective  tissue  fibres. 

Specimen  prepared  by  the  author  and  stained  with  Mallory's  Phosphotungstic  acid,  Hematoxylin  stain. 

Fig.    130. — Lithograph    of    high-power    drawing    showing    the    construction    of    the    capsule    of    the 

granuloma  shown   in   Fig.    124. 

A — Blood   vessels.     B — Erythrocytes   in   vessels.     C — Erythrocytes   in   the   tissue. 

D — Polymorphonuclear  leucocytes.     E — Endothelial  cell  of  vessel.     G — Plasma  cell.     H — Fibroblast. 

Specimen  prepared  by  author,  stained  with  Hematoxylin  and  eosin. 


PLATE     XXXIV 


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Fig.  131 


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Fig.  132 


FIG     131 —Lithograph   of   high-power   drawing   of   epitheliated   granuloma    as   shown    in   Fig. 

124,  showing  the  inner  part. 

A-Fibroblast.     B— Plasma    cells.     C— Hyalin    bodies      D— Eosinophils      E— Lymphocytes. 

F— Leucocytes     between     epithelial     cells.      G— Island    surrounded     by    epithelium. 

H — Epithelial  cells. 

Specimen  prepared  by  author  and  stained  with   Hematoxylin   and  Eosin. 

FIG    132  —Lithograph  of  high-power  drawing   of  the  inner  part  of  the   granuloma   shown  in 

Fig.    128,   showing  the  upper  branch   of  the  sinus. 

A— Mouth  of  sinus.     B— Plasma   cells.     C— Blood  vessels.     D— Leucocytes. 

E— Polymorphonuclear  leucocytes.       F— Pus   cells.       H— Epithelial   cells. 

Specimen   prepared   by  author   and  stained   with   Hematoxylin  and   Eosm. 


PLATE    XXXV 


Fig    133 


Fig.  134 


Fig.  135 


Fig.  133. — Kadiograph  showing  lateral  incisor  just  after  the  root  canal  had  been 
treated  and  filled.     A  light  circle  marks  the  circumference  of  the  granuloma. 

Fig.  134. — Photograph  of  the  same  granuloma  shown  in  Fig.  133  after  its  excision. 

Fig.  135. — Microphotograph  of  granuloma  shown  in  Fig.  133  showing  a  distinct 
capsule  and  numerous  spaces  which  were  occupied  by  cholesterin  crystals.  Note 
pink  and  blue  appearance,  the  first  represents  fibrin,  the  second  collagen  formation. 

Specimen  prepared  by  the  author,  stained  by  Mallory's  connective  tissue  stain. 


HISTOLOGICAL  PATHOLOGY  81 

lation.  Bacteria  and  toxins  may  be  absorbed  by  the  capil- 
laries in  the  granuloma  and  transported  to  other  parts  of 
the  body.  The  inner  part  of  the  granuloma  is  made  up 
of  granulation  tissue  (fibroblasts  and  vascular  endoth- 
elium) infiltrated  by  one  large  mass  of  plasma  cells. 
These  are  seen  as  cells  with  irregular  cytoplasm  which 
has  marked  basophilic  properties  containing  from  one  to 
four  nuclei  in  eccentric  arrangement.  If  there  are  proc- 
esses of  retrogression  going  on  we  find  also  numerous 
polymorphonuclear  leucocytes,  endothelial  leucocytes, 
lymphocytes,  eosinophiles  and  mast  cells  abundant  more 
or  less.  Erythrocytes  are  found  distributed  sometimes 
throughout  the  granuloma,  at  other  times  only  in  the 
fibrous  encapsulation;  their  presence  is  due  to  haemor- 
rhage of  extended  capillaries  during  extraction. 

Epitheliated  granuloma.  Remnants  of  the  embryonic 
enamel  organ  are  commonly  found  in  the  normal  perio- 
dontal membrane  of  animals  as  well  as  man.  They  can 
easily  be  seen  with  the  microscope  and  occur  either  in 
small  groups,  islands  or  in  chains.  But  the  presence  of 
epithelium  is  not  constant  in  the  periodontal  membrane, 
as  has  been  demonstrated  by  Malassez,  and  therefore  we 
do  not  find  epithelium  in  all  dental  granulomata.  This 
epithelium  may  be  found  only  near  the  root  of  the  tooth 
in  small  areas  or  it  may  be  found  throughout  the  granu- 
loma, having  proliferated  from  the  normal  remnants, 
stimulated  by  the  irritating  influence  of  chronic  inflam- 
mation. The  cells  of  the  proliferating  epithelium  differ 
in  appearance  from  the  cells  of  the  epithelial  islands; 
they  become  larger,  the  cytoplasm  and  nucleus  become 
more  distinct,  and  leucocytes  invade  the  intercellular 
substance  which  loosely  connects  the  various  cells.  The 
epithelial  strands  are  of  uneven  thickened  bands  radiat- 
ing from  the  original  island  in  various  directions,  and 
form  when  examined  in  a  microscopic  section  a  wide 
meshwork  throughout  the  granulation  tissue.  The  epith- 
elium has  further  the  tendency  to  grow  between  live  and 
necrosed  tissue,  and  it  has  sometimes  the  appearance  of 
encapsulating  the  seat  of  suppuration. 


82  OKAL  ABSCESSES 


Granuloma  with  Lumen.  Suppuration  of  the  simple 
or  epitheliated  granuloma  frequently  sets  in  either  near 
the  apical  foramen  from  where  the  bacteria  emigrate  or 
farther  in  the  center.  If  the  destructive  process  becomes 
severe  a  subacute  alveolar  abscess  results  with  subperios- 
teal or  subgingival  parulis  and  sinus  formation.  After 
the  accumulated  pus  is  discharged  the  symptoms  will  soon 
quiet  down,  but  the  pus  formation  may  persist  in  a  mild 
way  and  discharge  through  a  chronic  sinus,  as  seen  in 
Figure  128.  The  granulation  tissue  first  shows  a  large 
infiltration  of  polymorphonuclear  leucocytes  and  later 
areas  of  necrosis  in  the  center.  After  a  while  the  pus 
may  be  resorbed  and  if  the  leucocytic  infiltration  stops,  a 
lumen  remains,  containing  necrosed  tissue.  (Figures  124 
to  127.) 

Besides  suppuration  we  may  also  find  fatty  degenera- 
tion, especially  at  the  periphery  between  the  fibrous  cap- 
sule and  the  granulation  tissue.  In  old  conditions  there 
are  also  other  retrograde  processes  such  as  the  formation 
of  cholesterin  crystals,  which  are  recognized  by  the  rhom- 
boid shaped  spaces  left  by  the  crystals,  which  dissolve 
during  dehydration  in  alcohol.  They  can  be  demon- 
strated, however,  in  frozen  section  and  appear  as  brown- 
ish crystals.  Foreign  body  giant  cells  frequently 
surround  one  or  more  crystals,  as  seen  in  Figure  137. 
Compare  also  cholesterin  spaces  in  Figure  124  and  Figure 
135.  Collagen  is  formed  by  the  fibroblasts  from  the  fibrin 
which  stains  blue  with  Mallory's  aniline  blue  connective 
tissue  stain  in  contrast  to  the  fibrin  and  fibroglia  fibres 
which  are  stained  red,  as  seen  in  oil  immersion  drawing 
Figure  136. 

Another  retrograde  process  is  the  hyalin  formation 
which  occurs  in  droplets  of  various  sizes  in  the  cytoplasm 
of  the  plasma  cells  (Russell's  fuschsin  bodies).  This 
causes  the  cells  to  enlarge  and  often  nothing  remains  of 
the  cell  but  the  acidophilic  hyaline  bodies.  These  are  usu- 
ally diffusely  scattered  through  the  whole  granuloma. 

Cysts.  In  the  epitheliated  granuloma  with  lumen  we 
frequently  find  an  attempt  of  the  epithelium  to  line  the 


PLATE     X  XXV 


Fig.  136 


Fig.  137 


Fig.  136. — Lithograph  of  high-power  drawing  showing  the 

construction  of  the  granuloma  shown  in  Fig.  135. 

A,  Fibroblasts,  with  fibroglia  fibres.     B,  Fibrin. 

C,  Collagen. 

Fig.   137. — Lithograph   of   high-power    drawing   showing 

the  construction  of  another  part  of  the  granuloma  shown 

in  Fig.  135. 

A,  Fibroblast,  with  fibroglia  fibres.     B,  Fibrin. 

C,  Erythrocyte.     D,  Connective  tissue  bundles. 

E,  Space  from  cholesterin  crystal. 

F,  Giant  cell  enclosing  cholesterin  spaces. 


HISTOLOGICAL  PATHOLOGY  83 

central  space.  This  influenced  the  German  writers  to  call 
Epitheliated  gramilomata  with  lumen  formation,  "root 
cysts.''  Dependorf,  in  a  lengthy  article,  describes  with 
careful  illustrations  the  formation  of  cysts  from  dental 
granulomata.  The  author  agrees  that  cysts  may  be 
formed  in  both  jaws  from  such  conditions,  but  this  must 
happen  extremely  seldom  or  we  would  meet  with  cysts 
more  commonly  in  these  days  where  granulomata  are 
found  in  almost  everybody's  mouth. 


CHAPTER  VIII 


SECONDARY    COMPLICATIONS 

The  acute  forms  of  oral  abscesses  have  always  been 
more  or  less  feared,  more  because  of  their  violent  symp- 
toms than  on  account  of  the  serious  complications  which 
may  result  if  treatment  is  neglected  or  if  the  cause  is 
not  removed.  The  chronic  forms,  on  the  contrary,  have 
mostly  gone  unnoticed,  although  they  occur  much  more 
frequently.  They  were  not  properly  recognized  until 
the  radiograph  became  essential  as  a  means  of  diag- 
nosis and  only  recently  we  became  aware  of  the  fact  that 
almost  every  devitalized  tooth  develops  this  condition. 
In  my  opinion,  it  is  a  fair  estimate  to  say  that  seventy- 
five  per  cent,  of  the  population  of  this  country  harbors 
this  lesion  in  the  mouth.  In  the  Robert  B.  Brigham 
Hospital  for  chronic  invalids  I  found  that  of  eighty-two 
patients,  seventy-three  suffered  from  chronic  abscesses; 
some  of  them  also  had  pyorrhoea,  and  in  the  mouths 
of  these  seventy-three  patients  I  found  three  hundred  and 
thirty-four  abscesses. 

The  fact  that  these  chronic  abscesses  give  little  or  no 
local  symptoms  is  the  reason  why  the  dental  profession 
at  large  has  not  been  aware  of  what  is  going  on.  But 
the  last  few  years  the  deceiving  character  of  these  lesions 
has  come  to  light.  Radiographic  diagnosis,  keen  obser- 
vation and  research  have  revealed  the  knowledge  of  the 
grave  consequences  of  such  conditions.  These  septic  foci 
not  only  are  liable  to  spread  disease  to  the  adjoining 
parts,  but  also  cause  disturbances  in  organs  and  tissues 
quite  remote  from  the  teeth. 

Continuous  Infection.  The  infection  is  liable  to  spread 
to  adjoining  parts  and  involve  large  areas  of  the  mandib- 
ular or  maxillary  bones,  the  antrum  of  Highmore  or  the 
throat. 


SECONDAEY  COMPLICATIONS  85 

Referred  Nervous  Irritation.  Reflex  manifestations 
from  one  branch  of  the  fifth  nerve  to  another  or  to  com- 
municating nerves  is  of  quite  frequent  occurrence,  but 
often  such  pains  are  due  to  the  most  obscure  causes,  found 
only  after  a  most  painstaking  examination. 

Infections  through  the  Alimentary  Canal.  Abscesses 
with  sinuses  or  pyorrhoea  pockets  as  well  as  septic  sur- 
face lesions  of  the  mouth  discharge  their  pus  into  the  oral 
cavity  where  it  mingles  with  the  fluids  of  the  mouth  and 
when  swallowed  reaches  the  stomach  and  intestine.  The 
persisting  infection  through  this  channel  gives  rise  to 
most  serious  diseases  of  the  mucosa  of  the  alimentary 
canal.  From  these  secondary  lesions  bacteria  may  be 
absorbed  into  the  circulation,  in  turn  causing  other  dis- 
eases by  haematogenous  infection. 

Lymphatic  Infection.  The  lymphatic  system  and  espe- 
cially the  lymph  glands  have  the  office  of  absorbing  and 
disposing  of  harmful  substances,  such  as  liberated  in  all 
inflammatory  conditions.  A  certain  amount  of  pus  may, 
however,  reach  the  circulation  via  the  lymph  system, 
while  not  infrequently  we  find  the  lymphatics  or  the 
glands  seriously  affected. 

Haematogenous  Infection.  Abscesses  especially  of  the 
proliferating  type  which  have  no  outlet  into  the  mouth, 
contain,  as  we  have  seen,  numerous  capillaries  and  blood 
vessels.  Absorption  of  products  of  inflammation  into  the 
blood  stream  is  usually  small  in  quantity,  but  constantly 
wears  out  the  protective  cells  and  causes  diseases  of  the 
blood  and  secondary  infections  in  other  parts  due  to 
transported  bacteria,  or  toxin,  or  both.  The  bacteria  and 
products  of  infection  are  not  only  absorbed  from  the 
original  focus,  but  also  from  secondary  diseases  of  the 
lymph  system  or  the  alimentary  canal  as  already  men- 
tioned. 

The  complications  which  arise  from  septic  foci  in  the 
mouth  will  not  be  classified  in  this  book  according  to  the 
mode  of  infection,  but  the  various  disturbances  and  dis- 
eases which  have  been  found  due  to  oral  abscesses  will  be 


86  ORAL   ABSCESSES 


considered  in  turn.  Case  reports  are  here  given  so  as  to 
illustrate  the  connection  of  the  oral  abscesses  with  the 
various  systemic  diseases. 

1.    Involvement  of  Neighboring  Parts. 

The  inflammation,  whether  from  acute  or  chronic  ab- 
scess, is  liable  to  spread  to  adjacent  parts.  The  spreading 
to  and  involvement  of  other  teeth  has  been  mentioned  at 
another  place.  It  has  also  been  explained  that  necrosis, 
osteitis,  or  osteomyelitis  is  involved  in  every  case  of  alve- 
olar abscess  in  a  mild  and  localized  way.  These  diseases 
may  become  continuous  and  involve  large  parts  of  the 
maxillary  and  mandibular  bones  if  the  conditions  are 
right. 

Maxillary  sinusitis  or  empyema  of  the 

MAXILLARY 


antrum  of  Highmore  is  very  frequently 

met  with  by  the  rhinologist  as  well  as  by 
the  oral  surgeon.  About  75%  of  the  cases  are  due  to 
dental  origin  and  most  are  a  sequel  to  oral  abscesses. 

Etiology:  Acute  maxillary  sinuses  occur 
maxTllary  on^  as  ^^u^  °f  nasal  or  dental  diseases. 
sinusitis         ^he  nasal  sources  are  coryza,  influenza, 

tuberculosis  and  syphilis  of  the  nasal  mu- 
cous membrane,  and  any  suppurative  process  in  the  nose 
or  other  accessory  sinuses.  Dental  sources  are  acute  al- 
veolar abscess  on  an  upper  bicuspid  or  molar  discharging 
into  the  antrum,  infection  from  a  chronic  abscess  or  osteo- 
myelitis in  the  maxillary  bone.  Infected  dental  pulps 
and  root  canal  instrumentations  have  been  mentioned  as 
etiological  factors  in  cases  where  the  roots  project  into 
the  antrum.  Infection  is  liable  to  occur  from  the  extrac- 
tion of  a  tooth  or  root,  if  a  root  is  pushed  into  the  antrum, 
or  if  infected  tissue  or  pus  is  forced  into  it  and  by  the 
introduction  of  unclean  instruments. 

Symptoms:  The  cheek  on  the  infected  side  becomes 
reddened  and  tender,  and  often  there  is  a  marked  oede- 
matic swelling  which  may  close  the  eye.  The  patient  com- 
plains of  a  fullness  in  the  affected  side,  with  a  dull  throb- 
bing pain,  and  generally  malaise,  dizziness,  and  photo- 


SECONDARY  COMPLICATION'S  87 

phobia.  There  may  be  discharge  of  pus  through  the  nos- 
tril, or  if  the  patient  lies  in  bed,  into  the  pharynx.  Often 
the  osteum  is  closed  up,  when  the  pain  and  fullness  be- 
comes more  marked,  and  is  relieved  if  part  of  the  pus 
escapes  into  the  nose.  Headaches  and  neuralgic  face- 
aches  are  principally  found  in  less  severe  cases. 

Clinical  signs:  Fever  is  always  present  in  acute  cases 
and  may  reach  104  °F.  An  examination  of  the  nares 
shows  usually  crusts  of  pus  and  congested  mucous  mem- 
brane. In  doubtful  cases  the  patient  should  be  asked  to 
sleep  on  the  suspected  side  and  notice  in  the  morning 
whether  there  is  any  discharge  upon  turning  the  head  to 
the  other  side.  The  patient  may  be  asked  to  apply  suc- 
tion to  the  nose  while  closing  the  nostrils.  Transillumi- 
nation shows  bright  illumination  under  the  orbit  of  the 
healthy  face  and  darkness  on  the  other.  Radiographic 
examination  is  the  surest  means  of  diagnosis.  The  dis- 
eased antrum  presents  an  opaque  appearance  on  a  frontal 
plate,  and  a  lateral  view  shows  the  cause  if  it  is  of  dental 
origin.  Intraoral  films  are  a  great  help  to  diagnose  the 
etiological  factor,  but  are  of  no  value  in  the  diagnosis  of 
the  condition  of  the  antrum. 

Treatment  of  Acute  Maxillary  Sinusitis  from  the  Nasal 
Cavity.  In  cases  of  nasal  origin  the  treatment  is  under- 
taken through  the  nose,  but  also  in  certain  dental  cases 
this  treatment  is  indicated,  especially  if  the  inflammation 
of  the  antrum  occurs  after  an  extraction,  the  socket  hav- 
ing healed  up  before  the  complication  sets  in. 

1.  Irrigation  Through  the  Natural  Orifice.  In  mild 
cases,  which  respond  easily  to  treatment,  daily  irrigation 
and  medication  through  the  osteum  is  sufficient. 

2.  Perforation  of  the  Nasal  Wall.  If  drainage  and 
treatment  through  the  natural  orifice  is  not  sufficient,  per- 
foration of  the  naso-antral  wall  with  a  trocar  and  cannula 
is  recommended.  The  opening  should  be  made  as  near 
the  floor  of  the  antrum  as  possible.  This  closes  up  in  a 
comparatively  short  time,  and  resection  of  a  larger  part 
of  the  wall  is  recommended  if  a  more  permanent  opening 
is  desired. 


ORAL   ABSCESSES 


Treatment  of  Acute  Maxillary  Sinusitis  from  the  Oral 
Cavity.  It  has  already  been  stated  that  in  a  large  number 
of  cases  maxillary  sinusitis  is  due  to  abscessed  teeth.  The 
radical  removal  of  the  cause  is  naturally  the  first  step, 
but  this  also  furnishes  an  opening  into  the  antrum 
through  which  treatment  can  be  undertaken.  The  open- 
ing is  enlarged  with  the  surgical  burr  and  all  granulations 
and  diseased  bone  should  also  be  carefully  removed.  The 
antrum  is  then  washed  out  through  the  wound  by  inserting 
a  sterile  soft  rubber  catheter,  to  which  the  antrum  syringe 
or  fountain  syringe  is  attached.  Use  lukewarm  normal 
salt  solution.  If  the  osteum  is  closed,  spray  the  antral 
side  of  the  middle  meatus  with  Sol.  Adrenalin  hydro- 
chlorid  1 :6000.  This  will  contract  the  mucous  membrane 
and  reopen  the  natural  passage  way.  After  the  washing 
has  been  completed,  close  the  wound  with  sterile  gauze. 
The  washing  can  be  repeated  in  the  same  maner  until  the 
antrum  is  healed,  when  the  socket  should  be  closed  by  a 
plastic  operation.  If  the  antrum  is  opened  accidentally 
after  extraction,  and  curetting  for  alveolar  abscess,  espe- 
cially if  we  desire  to  remove  diseased  bone,  it  is  advisable 
to  clean  first  the  socket  thoroughly  and  then  insert  a 
sterile  soft  rubber  catheter,  washing  the  antrum  out  as 
above.  Carefully  close  the  wound,  and  if  no  reinfection 
occurs  the  condition  will  heal  without  trouble. 

Etiology :  The  chronic  form  of  maxillary 
max?llary  sinusitis  or  chronic  empyema  of  the  an- 
sinusitis         tram  frequently  follows  the  acute  form. 

Often  we  find  old  chronic  cases  which 
never  were  preceded  by  any  acute  or  painful  condition. 
In  these  cases  granulation  is  very  pronounced  and  the 
cavity  is  filled  with  polypi.  Abscessed  teeth  play  a  most 
important  part  in  the  etiology  of  chronic  maxillary 
sinusitis. 

Symptoms :  Pain  in  the  cheek,  which  is  often  of  neu- 
ralgic character,  is  almost  always  the  symptom  from 
which  the  patient  seeks  relief.  The  discharge  of  pus 
through  the  nostril  of  the  affected  side  is  at  times  very 
marked  and,  moreover,  it  is  often  of  very  offensive  odor. 


SECONDARY  COMPLICATIONS  89 

The  osteum  becomes  occasionally  obstructed,  which  in- 
creases the  severity  of  the  symptoms.  The  patient  almost 
always  loses  weight.  General  malaise,  arthritis,  gastric 
disturbances  from  swallowing  pus,  and  mental  depression 
frequently  accompany  the  disease. 

Clinical  signs:  What  has  been  said  for  the  acute  con- 
dition is  also  true  for  the  chronic.  The  differentiation  of 
acute  and  chronic  empyema  of  the  antrum  cannot  be 
easily  made  either  by  transillumination  or  by  radio- 
graphic examination.  The  history  of  the  case  and  con- 
sideration of  the  etiological  factor  will  help  in  ascertain- 
ing the  condition,  but  a  sure  diagnosis  can  only  be  made 
by  actual  examination.  Holmes's  naso-pharyngoscope  is 
a  great  help  for  this  purpose.  A  short  incision  in  the 
canine  fossa  allows  us  to  make  an  opening  through 
the  anterior  wall  with  a  surgical  burr,  through  which 
the  naso-pharyngoscope  is  inserted.  The  condition  of  the 
mucous  membrane,  the  amount  and  quality  of  new  growth 
can  plainly  be  seen.  This  is  the  safest  way  of  making  a 
differentiating  diagnosis. 

Treatment:  The  cause  of  the  disease  has  to  be  ascer- 
tained and  thoroughly  removed.  Frequently  we  find 
cases  of  maxillary  sinusitis  which  have  not  improved,  al- 
though a  great  amount  of  time  has  been  spent  for  treat- 
ment. After  careful  examination  we  find  that  a  tooth  is 
continuing  to  reinfect  the  mucous  membrane.  To  try  to 
save  one  tooth  if  two  are  involved  is  poor  judgment  if  we 
consider  how  difficult  a  task  it  is  to  cure  chronic  maxillary 
sinusitis. 

There  are  a  large  number  of  methods  for  treatment  of 
chronic  empyema. 

Treatment  Through  the  Alveolar  Border.  The  method 
of  draining  the  antrum  through  the  alveolar  process  has 
been  in  great  favor  with  the  dentists.  Some  have  even 
gone  so  far  as  to  treat  the  antrum  through  the  root  canal 
of  a  tooth.  If  we  compare  the  small  size  of  a  root  canal 
even  when  enlarged  with  the  capacity  of  the  antrum  hold- 
ing 12  to  52  c.c.  of  fluid  we  must  see  the  impossibility  of 
such  an  undertaking,  not  to  speak  of  the  consideration  of 


90  ORAL  ABSCESSES 


that  tooth  and  the  infected  periapical  tissue  as  a  causa- 
tive factor  which  ought  to  be  removed.  The  tooth  socket 
sufficiently  enlarged  with  a  surgical  burr  is  the  most  ideal 
place  for  drainage,  as  it  is  at  the  lowest  level.  The  an- 
trum should  be  washed  with  the  greatest  aseptic  precau- 
tions. A  soft  rubber  catheter  can  be  introduced  and  is 
connected  either  with  the  fountain  or  the  antrum  syringe. 
I  use  warm  normal  salt  solution  or  mild  antiseptics  as 
washings,  occasionally  with  application  of  fifteen  per 
cent.  Argyrol.  After  washing  the  antrum,  care  should  be 
taken  to  remove  all  the  moisture,  as  the  antrum  is  an  air 
sinus  with  dry  mucous  membrane.  Frequently  I  use 
filtered  compressed  air  for  this  purpose,  administered 
through  the  catheter.  The  washings  should  be  under- 
taken first  daily  and  later  at  intervals  until  there  is  no 
discharge  for  two  weeks.  It  is  important  to  construct  a 
rubber  or  gutta  percha  obturator  to  fit  into  the  alveolar 
socket  principally  to  prevent  food  and  saliva  from  enter- 
ing the  antrum,  but  also  to  keep  the  opening  from  closing 
up.  After  the  antrum  has  healed  the  socket  should  be 
closed  permanently  by  a  plastic  operation. 

Operation  Through  the  Canine  Fossa.  In  cases  where 
examination  of  the  antrum  reveals  granulations  and  new 
growth,  the  foredescribed  method  is  not  sufficient  to  re- 
sult in  a  cure.  Surgical  removal  of  all  growth  is  indi- 
cated. In  cases  of  malignant  growth,  the  lining  mem- 
brane should  be  removed  radically,  but  in  all  cases  of 
polypous  and  granulating  character  the  tendency  is  to  be 
contented  to  remove  the  growth  and  not  the  membrane. 
A  great  deal  depends  in  this  operation  on  being  able  to  see 
all  parts  of  the  antrum,  and  the  operation  should  there- 
fore be  performed  from  the  place  which  gives  the  best 
access  to  vision  as  well  as  instrumentation,  and  this  is  the 
canine  fossa. 

The  antrum  is  opened  from  the  canine  fossa  by  excising 
the  anterior  wall  with  chisel  and  surgical  burrs.  The 
opening  should  be  made  large,  but  care  should  be 
taken  not  to  injure  the  nerves  and  vessels  of  the  teeth. 
After  the  cavity  has  been  freed  from  polypi,  or  other 


PLATE     XXXVII 


w' 


Fig.  138. — Antrum  exposed  so  as  to  show  the  abscess  formed  at  the 
floor  by  the  upper  first  molar. 


PLATE     XXXVIII 


Fig.  139 


Fig.  140 


Fig.   139. — Radiograph  of  Case  No.   1,  showing  the  condition  of  the  upper  first 
molar,  causing  the  disease  of  the  antrum. 

Fig.  140. — Radiographic  plate  of  Case  No.  1,  showing  healthy  antrum   (dark)   on 
the  left  side  of  the  picture,  diseased  antrum   (cloudy)   on  the  right  side. 


SECONDARY  COMPLICATION'S  91 

growth,  and  from  bone  septa,  the  extraction  of  the  in- 
volved teeth  is  undertaken.  Chronic  abscesses  are  to 
be  extensively  removed  and  osteomyelitic  bone  is  curetted. 
After  washing  out  all  debris  and  diseased  tissue  the  cavity 
is  dried  out,  the  alveolar  wound  closed  by  sutures,  and  the 
antrum  packed  with  antiseptic  gauze  which  should  re- 
main in  place  for  about  forty-eight  hours.  Then  the 
gauze  is  removed,  the  cavity  again  irrigated,  dried  and 
repacked.  This  treatment  should  be  continued  for  about 
ten  days,  after  which  time  an  obturator,  which  has  been 
constructed  from  gutta  percha  or  rubber,  is  inserted  to 
keep  the  antrum  open  for  irrigation  and  observation 
until  it  is  entirely  healed.  The  plug  then  can  be  left  out 
and  the  antrum  is  closed  by  a  plastic  operation. 

Operation  Through  .Canine  Fossa  and  Treatment 
Through  Nasal  Wall.  (Caldwell-Luc.)  The  operation  is 
undertaken  through  the  canine  fossa  which  is  closed  up 
immediately  afterwards.  The  after-treatment  is  then 
continued  through  the  opening  in  the  antro-nasal  wall 
which  is  usually  of  permanent  character. 

Operation  Through  Canine  Fossa  and  Treatment 
Through  Alveolar  Socket.  The  canine  fossa  operation  is 
performed  as  described,  but  the  alveolar  wound  is  kept 
open.  The  opening  in  the  canine  fossa  is  closed  after  the 
healing  has  progressed  to  a  satisfactory  stage.  An  ob- 
turator is  constructed  for  the  alveolar  opening  to  close 
the  communication  of  the  antrum  and  mouth  after  each 
irrigation.  When  the  condition  is  cured,  the  alveolar 
opening  is  also  closed  by  plastic  methods. 

<5TRATivE  ^ase    !•     (Chronic    maxillary    sinusitis 
CASES  with,  polypoid  granulations.)       The  pa- 

tient, a  man  of  41  years  of  age,  presented 
symptoms  of  chronic  maxillary  sinusitis.  A  frontal  radio- 
graph is  shown  in  Figure  140,  and  the  cause  was  ascer- 
tained by  an  intraoral  film,  Figure  139.  The  upper  first 
molar  shows  chronic  abscesses  on  all  roots,  which  appa- 
rently infected  the  antrum.  Examination  of  the  nose  re- 
vealed no  infectious  condition.  Surgical  treatment  was 
undertaken  by  opening  through  the  canine  fossa.    A  large 


92  ORAL  ABSCESSES 


amount  of  polypoid  granulation  was  found,  the  antrum 
was  almost  entirely  filled  with  it.  I  removed  the  granu- 
lations, extracted  the  tooth  and  removed  all  diseased  bone 
with  surgical  burrs.  The  canine  fossa  was  permitted  to 
close  after  one  week,  and  the  treatment  continued  through 
the  alveolar  socket.  After  the  treatment  was  completed 
so  that  no  discharge  collected  during  a  period  of  three 
weeks,  I  closed  the  alveolar  opening  by  a  plastic  opera- 
tion. 

Case  II.  (Chronic  maxillary  sinusitis.)  The  patient,  a 
man  36  years  of  age,  suffered  from  obscure  pain  in  the 
maxillary  region.  The  two  upper  bicuspids  on  the  af- 
fected side  he  said  had  been  treated  several  times,  when 
it  was  observed  that  a  broach  could  be  pushed  up  a  sur- 
prisingly long  distance.  An  intraoral  film  showed  no 
extensive  periapical  condition;  a  frontal  radiograph  re- 
vealed a  slight  cloudiness  of  the  antrum.  I  opened  the 
antrum  from  the  canine  fossa.  Inspection  with  the  naso- 
pharyngoscope  showed  a  condition  similar  to  Figure  138, 
an  antral  abscess  on  the  floor  over  each  of  the  devitalized 
teeth.  The  roots  extended  into  the  antrum,  and  as  there 
was  no  bone  destruction,  there  was  nothing  to  show  in  the 
film.  Extraction  of  the  teeth  and  curettage  of  the  dis- 
eased part  was  the  first  step  in  the  treatment,  after  which 
the  slightly  inflamed  membrane  yielded  rapidly  to  treat- 
ment. 

PHARYNGITIS  P^^g^is  ve3T  frequently  occurs  as  a 
complication  of  abscesses  on  lower  im- 
pacted wisdom  teeth.  The  inflammation  may  spread  over 
one  side  of  the  pharynx  and  cause  the  patient  to  consult 
the  physician  while  the  real  cause  is  unnoticed  on  account 
of  lack  of  symptoms.     (Figure  95.) 

Symptoms :  Examination  of  the  mouth  usually  reveals 
the  true  character  of.  the  condition.  Sometimes  the  cusp 
of  an  unerupted  wisdom  tooth  is  visible,  and  upon  pres- 
sure on  the  lingual  part  of  the  gum  there  is  usually  more 
or  less  discharge  of  pus  through  the  gingival  opening.  A 
radiograph  aids  sure  diagnosis. 

Treatment :  The  cause  is  to  be  removed  at  once.  The 
pharyngitis  should  receive  general  and  local  attention. 


SECONDAKY  COMPLICATION'S  93 

illustrative  Case    III.      (Marked    pharyngitis    and 
CASE  slight  trismus.)     The  patient,  a  young 

man,  went  to  his  physician  for  treatment  of  the  throat. 
He  was  referred  to  me  and  when  he  came  to  my  office  the 
next  day  he  had  a  temperature  of  101  °F.,  enlarged  maxil- 
lary glands  on  the  left  side,  and  slight  trismus  of  the 
muscles  of  mastication.  On  examination  of  the  mouth 
and  pharynx,  I  found  the  right  side  badly  inflamed  and 
a  large  amount  of  pus  discharging  from  behind  the  lower 
second  molar.  The  radiograph  showed  the  cause  of  the 
trouble  as  an  impacted  unerupted  wisdom  tooth  with  ex- 
tensive abscess  formation. 
__.,,,,..„  Trismus  is  a  tonic  spasm  of  the  muscles 

TRISMUS  p  ,.       ,.  x 

oi  mastication. 

Etiology:  It  is  usually  caused  by  an  impacted  wisdom 
tooth  with  abscess  formation  and  periostitis. 

Symptoms:  The  patient  complains  of  not  being  able 
to  open  the  mouth  except  a  small  distance.  Sometimes 
the  teeth  are  locked  in  complete  occlusion.  Pain,  inflam- 
mation of  the  pharynx,  and  swelling  of  the  submaxillary 
glands  are  almost  always  found. 

Diagnosis:  By  means  of  an  extraoral  radiograph  we 
are  able  to  determine  the  cause  in  a  very  short  time. 

Treatment :  In  mild  cases  we  may  use  local  anaesthesia. 
After  the  inferior  alveolar  nerve  and  tissues  supplied 
have  been  anaesthetized  in  the  pterygo-mandibular  space 
by  the  intra-  or  extra-oral  method,  the  patient  is  relieved 
of  pain  and  usually  is  able  to  open  the  mouth  sufficiently 
for  the  operation.  It  is  advisable  to  insert  a  mouthprop 
for  the  patient  to  bite  on.  In  very  severe  cases  and  diffi- 
cult impactions  ether  anaesthesia  is  advisable.  The 
mouth  then  can  be  forced  open  by  means  of  the  mouth 
gag.  A  few  days  after  the  cause  is  removed  the  jaw 
regains  its  normal  function. 

Case  IV.      (Mandibular  trismus.)      The 

CASSTRAT'VE  patient,  aged  24,  suffered  from  pain  in 

the  trigeminal  region  for  several  days ;  he 

also  complained  of  severe  earache.     He  was  scarcely  able 

to  open  his  mouth.    An  X-ray  plate  showed  a  right  lower 


94  OEAL  ABSCESSES 


third  molar  which  had  been  decayed  and  abscessed.  The 
month  was  opened  under  ether  anaesthesia  and  the  tooth 
extracted.  An  iodoform  wick  was  inserted  for  drainage, 
the  patient  improved  rapidly  and  was  entirely  well  after 
one  week. 

2.     Ophthalmic  Disturbances. 

Ophthalmic  disturbances  due  to  oral  conditions  may  be 
brought  about  in  two  ways:  first,  through  nervous  irri- 
tation, and,  second,  through  haematogenous  infection. 

The  ophthalmic  division  of  the  fifth  nerve,  which  is 
purely  sensory,  supplies  the  eyeball,  the  mucous  mem- 
brane of  the  eye,  the  lacrimal  gland,  and  the  skin  of  the 
brow  and  forehead.  A  branch  of  the  second  division,  the 
orbital  nerve,  communicates  with  the  lacrimal  nerve; 
therefore  we  have  direct  communication  between  the  first 
and  second  divisions.  However,  the  teeth  are  also  con- 
nected with  the  eye  through  the  second  and  third  divi- 
sions via  the  Gasserian  ganglion.  The  first  division 
further  communicates  with  the  motor  nerves  of  the  eye, 
the  third,  fourth,  and  sixth  cranial  nerves.  Reflex  irri- 
tation from  the  oral  cavity  therefore  may  not  only  result 
in  irritation  of  the  parts  of  the  eye  supplied  by  the  sensory 
nerves,  but  may  also  cause  motor  nerve  disturbances  in- 
terfering with  the  function  of  accommodation  and  con- 
vergence. 

Haematogenous  infection,  however,  here  plays  an 
important  role.  To  me  it  seems  more  probable  that  secon- 
dary ophthalmic  disturbances  should  be  of  an  infectious 
nature.  They  may  also  have  been  predisposed  by  reflex 
nerve  irritation.  In  many  cases  there  may  be  found  a 
cause  in  the  mouth  for  referred  nervous  irritation,  but  al- 
most always  we  can  also  discover  a  septic  focus  such  as  a 
chronic  abscess,  an  abscess  around  and  caused  by  an  im- 
pacted tooth  from  which  the  secondary  disease  may  have 
originated.  There  is  no  doubt  that  oral  abscesses  as  well 
as  oral  nerve  irritation  cause  ophthalmic  disturbances  in 
many  instances,  such  as  iritis,  keratitis,  scleritis,  and 


PLATE     XXXIX 


CONJUNCTIVA 
BULBI 


CONJUNCTIVA 
PALPEBRAE 


N. OPTICUS 


Fig.  141. — Cross  section  through  eye. 


SECONDARY  COMPLICATIONS  95 

other  infectious  diseases  of  the  eye,  as  well  as  neurotic 
affections  such  as  intraocular  and  retrobulbar  optic 
neuritis. 

infectious  Conjunctivitis  is  an  inflammation  of  the 
coimjuncti-  conjunctiva,  the  thin  mucous  membrane 
vms  lining  the  eyelids.    We  distinguish  palpe- 

bral and  bulbar  types.     It  is  also  known  as  ophthalmia. 

Etiology :  Infectious  conjunctivitis  is  very  often  haem- 
atogenous  in  character,  but  may  also  be  the  result  of 
direct  contact,  as  by  means  of  the  fingers.  It  is  fre- 
quently found  in  children  and  may  easily  be  contracted 
from  abscessed  temporary  molars  if  the  child  carries  the 
finger  from  the  aching  tooth  to  the  eye. 

Symptoms :  The  conjunctiva  is  of  a  brilliant  red  color 
and  is  swollen.  The  discharge  is  mucopurulent,  some- 
times causing  blurring  of  the  sight.  There  are  itching  and 
smarting  sensations  referred  to  the  lids,  which  feel  hot 
and  heavy. 

suppurative  The  inflammation  of  the  cornea  is  called 
keratitis        keratitis. 

Etiology :  It  is  a  process  of  infection  caused  by  various 
organisms.  It  may  come  from  conjunctival  inflamma- 
tions or  other  direct  and  indirect  infections. 

Symptoms:  It  begins  with  a  dull,  grayish  or  grayish- 
yellow  infiltration  of  a  circumscribed  portion  of  the  cor- 
nea. It  may  extend  in  area  and  in  depth.  There  is  pain, 
photobia  (intolerance  to  light),  lacrimation  (excessive 
secretion  of  tears),  and  often  blepharospasm  (excessive 
winking). 

scleritis         ^ke  inflammation  of  the  sclera,  which 
with  the  cornea  forms  the  external  tunic 
of  the  eyeball,  is  called  scleritis. 

Etiology:  Scleritis  is  often  seen  in  connection  with 
rheumatism,  syphilis,  and  tuberculosis.  Exposure  to  cold 
is  sometimes  an  exciting  cause.  Reflex  irritation  and 
secondary  infection  from  oral  foci  are  not  uncommon 
causes. 

Symptoms:  There  is  usually  slight  discomfort,  lacri- 
mation and  pain. 


96  ORAL   ABSCESSES 


illustrative  Case  ^ '     (Bulbar   conjunctivitis.)     The 
case  "  Pa^en^    a    JowaS   man,    about    twenty- 

two  years  old,  had  suffered  for  a  long 
period  from  bulbar  conjunctivitis  of  both  eyes,  for 
which  he  was  treated  by  a  competent  ophthalmol- 
ogist, who,  however,  was  not  able  to  cure  the 
condition  permanently.  The  two  upper  central  in- 
cisors had  been  devitalized  and  in  the  radiograph 
showed  areas  of  lessened  density  around  their  apices. 
After  each  subacute  attack  of  these  abscesses  he  suffered 
from  an  attack  of  conjunctivitis.  The  root  canals  of  both 
teeth  had  previously  been  treated,  but  the  left  tooth  did 
not  yield  to  treatment.  I  treated  and  filled  the  left  in- 
cisor and  immediately  performed  apiectomy.  The  pa- 
tient was  normal  for  about  four  months,  when  he  had  a 
recurrence.  The  right  eye,  which  formerly  was  the  worst, 
showed  only  a  slight  conjunctivitis ;  the  left  eye  was  mod- 
erately inflamed.  The  right  central  incisor  again  felt 
lame.  I  undertook  at  once  to  take  radiographs  of  his 
whole  mouth  and  found  a  devitalized  right  lower  bicuspid, 
with  slight  periodontitis  and  poor  root-canal  filling.  A 
right  upper  bicuspid  showed  an  area  of  decreased  density. 
Upon  opening  into  this  tooth  the  eye  on  the  same  side 
cleared  up  almost  immediately.  The  tooth  was  treated 
twice  with  ionic  medication  and  then  filled  with  the  chloro- 
form-resin-gutta-percha method.  The  left  eye  stayed  in- 
flamed, the  inflammation  also  extended  into  the  conjunc- 
tiva and  did  not  improve  until  the  root  of  the  right 
central  incisor  was  amputated.  A  small  granuloma  was 
removed  with  the  root  end,  which  yielded  a  streptococcus 
and  staphylococcus  albus.  Three  days  after  the  opera- 
tion, when  the  patient  came  to  my  office  for  the  removal 
of  the  sutures,  his  eyes  showed  a  clear  and  healthy  ap- 
pearance. Before  this  case  is  dismissed  apiectomy  will  be 
performed  on  the  devitalized  upper  and  lower  bicuspids. 
iritis  Iritis  is  the  inflammation  of  the  iris,  and 

may  be  acute  or  chronic ;  primary  if  devel- 
oping in  the  iris  itself,  secondary  if  the  inflammation 
spreads  from  neighboring  parts,  such  as  the  cornea. 


SECONDARY  COMPLICATION'S  97 

Etiology :  Iritis  is  frequently  dependent  upon  some  con- 
stitutional disease  and  therefore  may  be  caused  by 
haematogenous  infection.  Frequently  the  focus  is  found 
in  the  nose  or  mouth. 

Symptoms:  There  is  pain,  photobia,  lacrimation,  and 
interference  with  vision.    The  iris  appears  swollen,  dull, 
with  indistinct  markings.    The  color  changes  and  becomes 
greenish  to  muddy  according  to  the  color  of  the  eyes. 
cyclitis  Iritis  is  frequently  associated  with  cycli- 

tis  which  rarely  occurs  alone.  (Iridocy- 
clitis.) It  is  an  inflammation  of  the  ciliary  body  and 
almost  always  involves  the  choroid. 

Etiology:  The  various  causes  of  iritis  are  responsible 
for  iridocyclitis.  "The  disease,"  writes  May,  "is  often 
due  to  the  influence  of  toxins  of  bacterial  origin  derived 
from  the  teeth  (abscesses  and  pyorrhoea  alveolaris)  ton- 
sils, pharynx,  nose,  and  sinuses." 

Symptoms :  In  iridiocyclitis  we  have  the  symptoms  of 
iritis  and  in  addition  tenderness  in  the  ciliary  region  and 
often  swelling  of  the  upper  lid. 

choroiditis    Choroiditis  may  be  non-suppurative  or 
suppurative.    In  the  latter  case  there  is 
usually  an  involvement  of  the  ciliary  body  and  the  iris. 
It  is  then  called  iridochoroiditis. 

Etiology :  The  condition  may  be  of  ectogenous  or  endo- 
genous origin.  The  latter  is  due  to  septic  infections  from 
the  oral  (abscesses  pyorrhoea)  and  nasal  cavities,  from 
intestinal  autointoxication,  syphilis  and  tuberculosis. 

Symptoms:  In  pure  choroiditis  there  are  no  external 
signs;  the  symptoms  are  disturbances  of  sight.  In  iri- 
dochoroiditis there  are  symptoms  of  iridocyclitis  which 
are  acute  and  severe. 

retinitis  ^e  inAainmation  of  the  retina  is  called 

retinitis. 

Etiology :  Retinitis  occurs  occasionally  as  a  local  lesion, 
but  almost  always  is  a  manifestation  of  a  constitutional 
disease,  autointoxication  or  secondary  infection. 

Symptoms:  Diminution  of  acuteness  of  vision  is  usu- 
ally present.  Pain  is  rare  and  there  are  no  external 
signs. 


98  ORAL  ABSCESSES 


intraocu-        in  this  type  of  optic  neuritis  the  head  of 

NEumTis'0        ^e  °P^C  nerve  is  affected,  causing  marked 
visible  changes  in  the  disc.     Intraocular 
neuritis  is  also  called  Papillitis. 

Etiology :  Among  the  causes  of  this  disease  we  have 
secondary  infections  from  diseases  of  the  nasal  cavity, 
the  sinuses  and  the  mouth  and  teeth. 

Symptoms :  Disturbance  of  vision  varies  and  there  may 
be  complete  blindness.  There  is  no  pain  and  no  external 
signs. 

retrobulbar  Retrobulbar  optic  neuritis  involves  the 
optic  orbital  portion  of  the  optic  nerve,  the 

neuritis  process   being   an   interstitial   neuritis. 

It  may  be  acute  or  chronic. 

Etiology:  It  may  be  due  to  direct  extension  from  the 
orbit,  general  diseases  or  haematogenous  infection.  Oral 
sepsis  plays  an  important  part  in  the  latter  factor. 

Symptoms :  In  the  acute  form  there  is  severe  headache 
on  the  affected  side,  pain  in  the  orbit  aggravated  by  move- 
ment of  the  eye  and  rapid  impairment  of  sight,  beginning 
in  the  center  of  the  field.  In  the  chronic  type  there  is 
diminution  in  acuteness  of  sight,  foggy  vision,  especially 
in  bright  light,  and  blindness  in  the  center. 

Case  VI.     (Retrobulbar  optic  neuritis.) 

caseTRAT,VE:  ^e  Patien^'  a  voung  woman,  was  sent  to 
me  by  an  ophthalmologist  of  this  city,  with 

the  following  letter:  "I  treated  Miss some  three  or 

four  years  ago  for  an  acute  retrobulbar  optic  neuritis  of 
each  eye.    At  that  time  we  could  trace  no  cause  for  the 

process.    About  ten  days  ago,  Miss  developed  the 

same  trouble  again  in  her  left  eye.  It  is  a  coincidence 
that  both  at  the  time  of  this  attack  and  at  her  previous 
attack  she  was  having  trouble  with  her  teeth.  I  am  send- 
ing her  to  you  to  get  an  opinion  as  to  what  sort  of  con- 
dition her  teeth  are  in  and  as  to  whether  there  might  pos- 
sibly be  an  infection  there  responsible  for  the  ocular 
trouble. ' ' 

The  patient  complained  of  blurred  vision ;  she  was  al- 
most blind  for  near  sight,  but  vision  for  distance  was 


PLATE     XLI 


Fig.  145 


Fig.  146 


Fig.  147 


Fig.  148 


hn?w™;-146'  14v  anai\8.— Radiographs  of  Case  No.  6,  a  patient  suffering  of  a  retro- 
bulbar optic  neuritis.     Both  maxillary  third  molars  are  impacted.     Areas  indicating  graim- 
lomata  are  found  on  devitalized  teeth. 


PLATE     X  LI  I 


Fig.  149 


Fig.  150 


Fig.    149. — Radiograph    showing    impacted   un- 

erupted    third    molar    causing    otitis    media    in 

Case  No.  7. 


Fig.  150. — Radiograph  showing  lower  second  bi- 
cuspid with  decay  under  filling  and  granuloma 
causing  otalgia  in  Case  No.  8. 


SECONDARY  COMPLICATION'S  99 

not  bad.  Upon  examination  of  the  mouth  several  poorly- 
fitting  gold  crowns  were  visible.  Kadiographic  examina- 
tion revealed  the  following  (Figures  145  to  148)  : 

Lower  jaw :  All  the  molars  of  the  left  side  showed  areas 
which  indicated  chronic  abscesses.  A  very  large  area  on 
the  right  second  bicuspid. 

Upper  jaw:  Third  molar  unerupted  and  impacted  on 
both  sides.  Left  upper  first  and  second  bicuspid  and 
right  upper  first  bicuspid,  first  and  second  molars  also  had 
apical  infections  to  a  greater  or  less  extent. 

I  extracted  all  these  teeth,  curetted  thoroughly  and 
treated  the  sockets  with  iodine.  The  patient  reported 
improved  ten  days  later,  and  since  then  has  been  steadily 
growing  better. 

glaucoma       Glaucoma  is  an  important  and  common 
disease  of  the  eye  which  has  for  its  charac- 
teristic an  increase  in  intraocular  tension.     It  may  be 
primary  or  secondary. 

Primary  glaucoma  occurs  without  antecedent  ocular 
disease,  and  is  divided  into  inflammatory  or  congested 
acute  and  chronic  stages  and  into  non-inflammatory  or 
simple  varieties. 

Secondary  glaucoma  is  the  name  given  to  cases  of  in- 
creased tension  and  other  symptoms  of  glaucoma  due  to 
some  other  ocular  diseases  or  injuries. 

Etiology :  The  exact  cause  of  primary  glaucoma  is  un- 
known. May  thinks  that  arteriosclerosis,  cardiac  dis- 
eases, chronic  constipation,  the  gouty  and  rheumatic 
diathesis  are  predisposing  factors,  all  diseases  which  are 
more  or  less  caused  by  toxic  or  bacterial  absorption. 

Symptoms :  There  are  different  stages  distinguished  in 
acute  inflammatory  glaucoma.  The  prodromal  stage: 
Sight  appears  to  be  obscured  by  a  fog,  with  slight  pain  in 
eye  and  head.  The  active  stage  of  glaucoma  (glaucoma- 
tous attack)  is  characterized  by  rapid  failure  of  sight, 
severe  pain  in  the  eye  and  violent  headache,  accompanied 
with  nausea,  vomiting,  and  general  depression.  After  a 
few  days  or  weeks,  a  decided  improvement  takes  place, 
but  the  normal  condition  does  not  return.    This  condition 


100  OKAL   ABSCESSES 


is  the  glaucomatous  stage.  At  any  time  there  may  be  new 
attacks  and  with  each  succeeding  attack  the  diminution 
in  vision  becomes  greater  until  blindness  ensues.  This 
stage  is  called  absolute  glaucoma.  Later  the  eyeball  is 
apt  to  degenerate. 

Chronic  inflammatory  glaucoma  is  much  more  common, 
the  symptoms  resemble  those  just  described,  but  are  less 
intense  and  more  gradual  in  onset.  The  termination  is 
absolute  glaucoma  and  finally  degeneration. 


3.    Aural  Disturbances. 

Pain  in  the  ear  is  a  very  frequent  symptom  of  oral 
diseases,  both  the  second  division  of  the  fifth  nerve  which 
supplies  the  upper  teeth  and  the  third  division  which 
supplies  the  lower  teeth  being  in  communication  with  the 
nerves  of  the  ear.  The  maxillary  division  is  connected 
with  the  tympanic  plexus  via  spheno-palatine  (Meckel's) 
ganglion,  the  vidian  and  greater  superficial  petrosal 
nerve.  The  mandibular  division  communicates  with  the 
tympanic  plexus  by  way  of  the  optic  ganglion  and  the 
small  superficial  petrosal  nerve. 

Such  irritation  of  the  middle  ear  referred 
media  through  nervous  channels  frequently  pre- 

disposes the  tissue  for  infection  and 
through  haematogenous  transportation  of  bacteria  may 
result  in  acute  median  otitis  as  well  as  chronic  purulent 
inflammation  of  the  middle  ear  and  tympanum.  Ab- 
scessed teeth  may  become  foci  for  purulent  otitis  in  two 
ways :  first,  by  discharging  a  large  amount  of  pus  into  the 
mouth,  which  may  reach  the  tympanic  cavity  via  the  Eus- 
tachian tubes.  It  is  well  known  that  middle  ear  inflam- 
mations occur  most  frequently  in  children  at  the  time 
when  they  are  about  to  lose  the  temporary  teeth,  which 
very  often  are  badly  neglected  and  abscessed.  The  patho- 
genic connection  between  teeth  and  middle  ear  has,  how- 
ever, not  alone  been  demonstrable  in  children.  Grayson 
reports  that  in  adults  he  has  failed  a  number  of  times  to 


PLATE      X  LI  I  I 


d       e  f        g       h 


/ 


Fig.  151. — Position  of  the  lymph  glands  beneath  the  lower  jaw 
(Preiswerk) . 

a,  Submental  lymph  glands.  ~b,  Digastric  muscle,  c,  Submax- 
illary gland,  d,  f,  h,  Submaxillary  lymph  glands,  A,  B,  C. 
e,  External  maxillary  artery,     g,  Masseter  muscle,     i,  Parotid 

gland. 


PLATE     XLI  V 


Pig.   152. — Schematic   drawing   showing  which   teeth   are   drained  by  the   various 

lymph  glands. 

A,  B,  C,  the  three  submaxillary  lymph  glands, 
i  S.  M.,  S.  M.,  the  submental  lymph  glands. 


SECONDAKY  COMPLICATIONS  101 

make  much  impression  upon  chronic  purulent  inflamma- 
tions of  the  tympanum  until  the  dental  cause  had  been 
removed. 
otalgia  Otalgia  or  pain  referable  to  the  ear  may 

be  from  the  Pinna,  the  external  auditory 
meatus,  the  tympanic  membrane,  the  tympanic  cavity, 
and  Eustachian  tubes,  from  the  mastoid  process,  or  a  re- 
flex manifestation. 

The  jaws  and  teeth  play  a  most  important 
OTALGIA  r^e  *n  re^ex  otalgia.     The  pain  may  be 

continuous  or  periodical,  with  remissions 
and  exacerbations.  The  cause  may  be  found  in  the  molar 
region,  usually  more  in  the  lower  than  in  the  upper  jaw. 
Impacted  teeth,  teeth  with  acute  or  chronic  abscesses, 
periostitis,  and  wounds  in  that  region  play  a  great  part  as 
etiological  factors. 

illustrative  ^ase  VH-     (Otitis  media.)     The  patient 
CASE  suffered  from  repeated  attacks  of  otitis 

media  of  the  right  ear.  There  was  a  large 
amount  of  discharge  from  the  ear.  Treatment  did  not 
result  in  permanent  relief,  and  pain  persisted  after  the 
inflammation  had  subsided.  The  specialist  she  consulted 
during  her  last  attack  in  San  Francisco,  before  she  left 
for  the  East,  advised  her  to  have  her  teeth  examined.  The 
patient  was  then  referred  to  me,  and  I  immediately  took 
radiographs  of  her  mouth.  There  was  a  large  area  over 
the  right  upper  second  bicuspid,  shadows  on  each  of  the 
roots  of  the  first  molar  and  a  badly  impacted  upper  wis- 
dom tooth  with  pus  discharge  from  an  opening  in  the  gum. 
I  extracted  the  upper  second  bicuspid  and  first  molar  and 
extirpated  the  impacted  third  molar  without  disturbing 
the  second  molar.  The  granulomata  were  removed  at 
once,  after  which  the  bone  was  thoroughly  curetted.  Local 
conductive  anaesthesia  was  used  for  the  operation,  which 
also  relieved  the  pain  in  the  ear  while  it  was  in  effect. 
During  the  after  treatment  the  patient  improved  rapidly 
and  was  freed  from  the  aural  pain  and  inflammation. 
(Figure  149.) 

Case  VIII.     (Otalgia.)     The  patient,  a  young  lady, 
referred  to  me  by  another  patient,  complained  of  earache 


102  ORAL  ABSCESSES 


on  the  right  side;  occasionally  also  had  what  she  called 
faceache  on  the  same  side.  She  consulted  two  dentists, 
who  failed  to  locate  the  cause  of  the  trouble,  and  was  about 
to  go  to  an  ear  specialist  when  her  friend,  who  had  a  simi- 
lar experience,  the  cause  of  which  I  was  able  to  locate  and 
remove,  advised  her  to  consult  me  first.  I  took  radio- 
graphs of  the  teeth  on  the  affected  side,  and  found  that 
the  right  lower  second  bicuspid  had  a  large  obscure  cavity 
at  the  distal  side,  underneath  the  cervical  margin  of  a 
gold  filling.  The  pulp  was  involved  and  a  granuloma  had 
developed  at  the  end  of  the  root.  There  were  no  symp- 
toms that  indicated  this  condition.  The  tooth  was 
extracted  and  the  bone  curetted,  which  resulted  in  per- 
manent relief  of  the  otalgia.     (Figure  150.) 

4.    Lymphatic  Infections. 

There  are  two  groups  of  lymph  glands  which  drain 
the  jaws  and  teeth  and  their  mucous  membrane.  The  sub- 
mental glands  take  care  of  the  region  of  the  lower  incisor 
teeth.  They  are  situated  behind  the  chin,  beneath  the 
fascia,  and  between  the  two  geniohyoid  muscles.  The 
other  group  are  the  submaxillary  lymph  glands.  They 
are  three  in  number.  The  anterior  one  lies  internally  to 
the  lower  border  of  the  mandible  and  anterior  to  the 
external  maxillary  artery.  It  is  connected  with  the  re- 
gion of  the  superior  incisors,  cuspids,  and  bicuspids,  also 
the  lower  cuspids,  bicuspids  and  the  lower  first  molars. 
The  middle  submaxillary  lymph  gland  lies  posterior  to 
the  external  maxillary  artery  at  the  anterior  part  of  the 
submaxillary  salivary  gland.  It  drains  the  parts  contain- 
ing the  maxillary  first  molar,  but  also  partly  the  upper 
bicuspids  and  second  molar.  In  the  lower  jaw  it  takes 
care  of  the  three  molars,  but  principally  of  the  second 
molar.  The  posterior  gland  is  situated  at  the  posterior 
pole  of  the  submaxillary  salivary  gland  and  is  connected 
with  the  upper  wisdom  tooth  exclusively,  and  also  with 


SECONDAKY  COMPLICATIONS  103 

the  lower  third  molar,  which  is  to  small  extent  drained  by 
the  middle  gland. 

These  just  described  lymph  glands  are  tributaries  of 
the  deep  cervical  lymph  glands  which  accompany  the  ex- 
ternal and  internal  jugular  veins. 

In  a  perfectly  normal  condition  these  glands  are  of 
very  small  size  so  that  they  are  hardly  noticeable ;  they  are 
seldom  larger  than  the  size  of  a  pea,  but  in  diseased  con- 
dition they  may  become  greatly  enlarged.  Lymphatic 
infections  occur  most  frequently  in  children,  but  are  not  a 
rare  occurrence  in  adults. 

Lymphangitis  is  an  inflammation  of  the 
GUIS  "  lymphatic  vessels,  and  also  gives  rise  to 
inflammation  of  the  tissue  immediately 
surrounding  them.  It  is  rarely  a  primary  condition  and 
usually  extends  from  the  focus  to  the  nearest  lymphatic 
gland,  but  may  continue  from  there  to  the  next  group  of 
lymph  glands. 

Etiology:  The  cause  is  always  a  septic  condition.  It 
occurs  in  the  mouth  occasionally  from  abscesses  or  other 
infections.  The  bacteria  or  their  toxins  are  absorbed 
from  the  focus  and  cause  inflammation  while  passing 
along  the  lymph  channels. 

Symptoms :  "We  can  easily  recognize  a  lymphangitis  by 
the  pink  or  reddish  colored  streaks  clearly  visible  on  the 
skin.  There  is  usually  more  or  less  pain  along  the  lym- 
phatic vessels  and  a  rise  of  the  temperature.  Lymphan- 
gitis from  lesions  in  the  mouth  is  only  recognizable  if  the 
lymphatic  channels  beyond  the  submental  or  submaxillary 
lymph  glands  are  affected,  in  which  cases  there  is  also 
swelling  of  these  glands.  The  affection  therefore  does 
not  point  directly  to  the  lesion  and  the  cause  has  to  be 
ascertained  by  radiographic  examination.  The  affected 
gland,  however,  indicates  the  location  of  the  focus. 

Treatment:  The  finding  and  removing  of  the  cause  is 
imperative  and  if  this  is  done  the  inflammation  will  dis- 
appear in  a  short  time.  Hot  applications  can  be  applied 
as  soon  as  the  focus  has  been  thoroughly  opened  and 
drainage  established. 


104  ORAL  ABSCESSES 


ILLUSTRATIVE  C™\  /X      (Lymphangitis.)      The    pa- 
c  s  tient,  a  woman  01  middle  age,  presented 

a  lymphangitis  extending  from  the  left 
submandibular  region  to  the  left  axilla  and  breast.  The 
lymphatic  channels  were  distinctly  outlined  in  reddish 
color.  The  submaxillary  and  cervical  glands  were 
slightly  enlarged  and  tender  on  pressure.  "No  pain  in  the 
mouth.  Radiographic  examination  revealed  a  large  area 
of  lessened  density  around  the  left  lower  second  bicuspid. 
(Figure  153. )  Examination  showed  slight  swelling  on  the 
gum  and  pus  discharge  at  the  gingival  margin  if  pressure 
was  applied.  The  treatment  consisted  in  extraction  of 
the  tooth,  thorough  curettage,  and  insertion  of  iodoform 
wick  for  drainage.  This  was  changed  until  the  discharge 
stopped  and  then  left  to  heal  up.  Bacterial  examination 
showed  a  streptococcus  and  staphylococcus  aureus 
infection.  The  inflammation  of  the  lymphatics  grad- 
ually diminished  and  disappeared  entirely  after  three 
weeks. 

lymph  a-  Lymphadenitis  is  the  term  applied  to  the 

denitis"  inflammation  of  the  lymph  glands.    We 

distinguish  acute,  chronic,  and  subacute 
lymphadenitis.  Submaxillary,  submental,  and  cervical 
adenitis  are  common  complications  of  diseased  teeth,  es- 
pecially in  children,  and  unfortunately  it  occurs  fre- 
quently that  the  glands  are  removed  without  investigat- 
ing the  unsuspected  cause,  which  almost  always  is  an 
acute  or  chronic  abscess,  from  a  temporary,  permanent, 
or  impacted  and  unerupted  tooth. 

acute  Acute  lymphadenitis  usually  occurs  in 

cervical  LYM-connection  with  acute  periodontitis   and 
phadenitis     acute  abscesses. 

Etiology :  Acute  lymphadenitis  is  usually  secondary  to 
a  septic  infection.  The  focus  for  the  submaxillary  and 
submental  lymph  glands  may  be  found  in  the  orbit,  zygo- 
matic and  temporal  fossae,  the  nose,  the  cheeks,  palate, 
lips  and  especially  the  alveolar  process  and  teeth  of  both 
jaws.    Alveolar  abscesses  and  stomatitis  are  the  most 


PLATE      XLV 


Fig.  153 


Fig.  154 


Fig.   153. — Radiograph   showing  the  tooth    (second  bicus- 
pid) causing  lymphangitis  of  Case  No.  9. 

Fig.    154. — Radiograph    showing   the    lower    second   molar 
causing  lymphadenitis  in  Case  No.  10. 


PLATE     XLVI 


Fig.   155 


Fig.  155a 


Figs.  155  and  155a. — Eadiographic  plates  of  Case  No.  11,  showing  the  un- 
erupted    third    molars    causing    chronic    lymphadenitis.         There    was    a 


,„„^  ,T„,.„V.l, 


SECONDARY  COMPLICATIONS  105 

frequent  causes.     The  toxins  or  bacteria  themselves  may 
be  absorbed. 

Symptoms :  The  glands  in  acute  lymphadenitis  become 
only  slightly  enlarged,  they  feel  elastic  and  soft,  and  are 
very  sensitive  on  palpitation.  But  also  the  tissues  sur- 
rounding the  glands  become  affected  by  the  process  of  in- 
flammation, the  skin  looks  red  and  swollen,  and  in  extreme 
cases  the  pus  may  burst  through  the  capsule  of  the  gland 
and  force  its  way  through  the  skin. 

Treatment:  Find  and  remove  the  focus  and  use  cold 
poultices  and  hot  mouth  wash  until  the  abscess  in  the 
mouth  has  healed,  then  apply  hot  poultices  to  the  glands. 
If  suppuration  has  progressed  beyond  the  stage  where 
nature  can  take  care  of  the  condition,  the  glands  should  be 
incised. 

illustrative  @ase  ^.      (Acute  Lymphadenitis.)      A 
case  7oung    man,    a    medical    student,    con- 

sulted me  for  tenderness  directly 
under  his  lower  jaw.  Upon  examination,  I  found 
the  middle  lymph  gland  of  the  right  submaxillary 
group  slightly  enlarged  and  very  tender ;  there  was  also 
enlargement  of  one  or  two  of  the  cervical  glands.  The 
examination  of  the  mouth  revealed  nothing  except  large 
amalgam  fillings  in  the  posterior  teeth.  I  took  a  radio- 
graph of  the  right  lower  molars  first,  and  was  at  once 
rewarded  in  finding  a  large  area  of  lessened  density  ex- 
tending from  the  roots  of  the  right  lower  second  molar. 
A  radiograph  of  the  upper  molars  showed  all  teeth  in 
normal  condition.  The  pulp  of  the  right  lower  molar  had 
never  been  touched  before,  but  apparently  was  infected. 
The  reason  why  there  were  no  other  symptoms  was  prob- 
ably due  to  the  thickness  of  the  outer  and  inner  plate  of 
the  mandible  in  this  region,  not  allowing  the  pus  to  pene- 
trate quickly  to  the  large  cancellous  inner  portion,  allow- 
ing the  pus  to  accumulate  without  causing  pressure  or 
pain.  When  I  opened  into  the  pulp,  I  found  what  I  ex- 
pected, namely,  an  extremely  putrescent  pulp.  After  the 
local  condition  was  treated,  the  glands  became  normal  in  a 
very  short  time.     (Figure  154.) 


106  ORAL  ABSCESSES 


CHRON8C  If  the  lymph,  glands  are  swollen  and  re- 

cervical  main  so  on  account  of  persistent  infection 

nrUmc"  ^or  a  l°ng  time,  we  have  chronic  lymph- 

adenitis. 

Etiology:  Chronic  lymphadenitis  is  a  secondary  infec- 
tion. It  is  caused  by  continuous  absorption,  such  as 
bacteria  from  chronic  abscesses  or  pyorrhoea. 

Symptoms:  The  glands  are  usually  much  larger  than 
in  the  acute  condition.  They  are  hard,  are  easily  palpi- 
tated, and  are  not  tender  on  touch.  They  are  not  adherent 
and  seldom  suppurate. 

Treatment :  The  focus  should  be  removed  because  there 
is  always  danger  of  a  secondary  infection  such  as  tuber- 
culosis, reaching  the  gland  via  the  primary  lesion. 
subacute         Subacute  lymph  glands  occur  from  sub- 
cervical  acute  attacks  in  the  primary  lesion. 

lymph  A-  Symptoms:  Besides  the  symptoms  caused 

denitis  about  the  focus,  we  find  the  lymph  glands 

very  large  and  extremely  tender.    This  is  characteristic 
for  subacute  attacks. 

Treatment :  The  treatment  is  the  same  as  for  the  acute 
condition. 

illustrative  Case XI'     (Cnronic  lymphadenitis.)    A 
CASE  young  lady  of  about  18  years,  was  sent 

to  me  with  radiographs  showing  four  im- 
pacted wisdom  teeth.  She  complained  of  swellings  in  the 
submaxillary  region,  which  from  time  to  time  became 
very  tender  and  painful.  On  examination  the  gums 
around  the  wisdom  teeth  are  found  red  and  inflamed,  dis- 
charging pus  on  pressure;  the  posterior  submaxillary 
lymph  gland  on  each  side  is  much  enlarged.  I  extracted 
all  four  impacted  teeth  under  ether  anaesthesia,  and  after 
the  wounds  had  healed  the  glands  diminished  gradually 
to  their  normal  size.  (Figure  155.) 
tubercular  Tubercular  cervical  lymphadenitis  is  more 
cervical  frequent  in  children  under  six  years,  but 
lymph  A-  is  not  a  rare  occurrence  in  adults.  That 
denitis  y.  occurs  independent  of  general  tubercu- 

losis   due    to    septic    infection    from    the    mouth    was 
shown    by    Professor    Cantani    in    fifty    clinical    ob- 


SECONDARY  COMPLICATIONS 107 

servations  at  the  Institute  of  Medical  Clinic  of  the 
Royal  University  of  Naples. 

Etiology :  The  cause  is  the  tubercle  bacillus,  which  may 
find  its  way  to  the  glands  via  the  lymph  system  or  circu- 
lation from  the  tonsils  or  the  teeth.  Carious  teeth  with 
open  pulp  chambers  are  an  ideal  place  for  the  entrance  of 
such  microorganisms. 

Symptoms :  The  glands  first  are  enlarged  and  firm,  and 
it  is  characteristic  that  in  a  short  time  other  glands  are 
involved  and  the  structures  in  the  vicinity  of  the  glands 
become  fused  together.  (Peri-adenitis.)  It  is  also 
characteristic  that  the  swelling  of  the  glands  does  not  go 
back  after  removal  of  the  focus.  In  cases  where  the  in- 
fection is  secondary  to  tuberculosis  of  the  lungs,  bones, 
etc.,  the  glands  do  not  become  excessively  enlarged,  but  in 
primary  infections  we  have  large  glands  which  tend  to 
break  down. 

Treatment :  The  treatment  more  or  less  depends  on  the 
question  whether  the  patient  suffers  from  general  tuber- 
culosis or  whether  the  cervical  lymphadenitis  is  only  a 
local  infection.  If  the  patient's  general  health  is  poor,  it 
should  be  improved  by  outdoor  life  and  plenty  of  good 
nourishment.  In  treating  local  conditions  we  should 
ascertain  and  radically  remove  the  cause.  Radiographic 
examination  is  necessary  to  ascertain  abscesses  resulting 
from  teeth,  because  chronic  abscesses  give  no  symptoms 
or  signs  to  indicate  the  condition.  The  removal  of  the 
cause,  however,  does  not  cure  a  cervical  tubercular  ade- 
nitis and  many  treatments  have  been  advised  for  this 
condition. 

Extirpation:  Surgical  removal  according  to  many 
writers  is  not  justified  in  cases  of  moderate  size  because 
they  claim  that  tubercular  adenitis  is  liable  to  recur.  I 
think  the  reason  for  the  recurrence  may  rather  be  found 
in  the  neglect  or  insufficient  treatment  of  the  cause  than  in 
the  method.  However,  it  may  be  advisable  to  try  one  or 
more  of  the  other  methods  before  resorting  to  radical 
means. 

Heliotherapy:  This  treatment  consists  in  exposing  the 
glands  to  direct  sunlight. 


108  ORAL  ABSCESSES 


Radiotherapy:  A  series  of  X-ray  treatments  has  been 
found  to  give  good  results.  The  X-rays  are  carefully 
filtered  to  prevent  burning  and  the  dosage  is  regulated 
according  to  the  patient  and  the  condition.  About  twenty 
treatments  applied  twice  a  week  are  said  to  be  sufficient. 
This  treatment  is  also  advised  in  cases  where  suppuration 
occurs.  The  abscess  may  be  punctured  if  a  sinus  does 
not  already  exist.  X-ray  treatment  is  also  beneficial 
after  extirpation  to  prevent  recurrence. 

Injections  of  Antiseptics :  Injections  into  the  glands  of 
iodine  or  carbolic  acid  have  been  advocated.  De  Vecchis, 
an  Italian  physician,  has  used  the  following  method  which 
had  not  failed  him  in  a  single  case,  and  has  the  advantage 
of  not  causing  a  permanent  scar  or  fibrous  thickening, 
which  fact  is  important  from  an  aesthetic  viewpoint, 
especially  in  women.  After  careful  search  for  and 
removal  or  treatment  of  the  focus  or  possible  foci  in  the 
mouth  and  throat,  he  injects  the  following  solution : 

Synthetic  guaiacol  Merck 6.0 

Metallic  iodine 3.0 

Sodium  iodid 6.0 

Glycerine    30.0 

Saccharin   0.5 

Aqua  dest 10.0 

Mx  et  solve. 

Sig.  for  injections. 

With  needles  of  special  size  he  makes  parenchymatous 
injections  with  this  solution,  turning  the  needle  in  all 
directions  in  the  gland  and  liberating  the  drug  drop  by 
drop,  using  1  to  2  c.c.  in  all.  The  injection  is  followed 
by  slight  massage  and  by  application  of  tincture  of 
iodine  and  warm  cotton  for  twenty  minutes.  When 
suppuration  has  begun,  he  aspirates  all  pus-like  liquid, 
and  if  the  patient  can  be  seen  daily,  he  also  uses  gluteal 
injections  of  1  c.c.  each  day.  In  regard  to  the  paren- 
chymatous injections  the  operator  should  be  particu- 
larly careful  in  regard  to  asepsis,  so  as  not  to  cause 
mixed  infection.    After  each  injection  the  gland  becomes 


SECONDABY  COMPLICATIONS 109 

more  tumid,  warmer  and  more  reddish,  but  after  one  or 
two  days  it  begins  to  diminish  in  size.  The  injection  is 
repeated  twice  a  week  for  three  to  four  weeks ;  the  patient 
is  directed  to  use  an  antiseptic  mouth  wash  and  gargle,  to 
avoid  smoking  and  drinking  of  intoxicating  beverages, 
and  is  advised  to  live  in  the  fresh  air  and  sleep  with  the 
windows  open,  to  eat  as  much  as  he  can  of  the  most 
nutritious  food. 

illustrative  ^ase  ^^'  (TuDercular  lymphadenitis.) 
CASE  (Case  reported  by  Stark  in  Revue  de  la 

Tuberculose,  July,  1896.)  A  youth  who 
had  always  been  healthy  previous  to  his  eighteenth  year, 
developed  at  that  age  enlarged  glands.  Carious  molars 
were  present  on  both  sides.  The  glands  were  removed  and 
the  teeth  extracted.  The  glands  proved  to  be  tuberculosis 
and  the  cover  slip  preparations  from  the  teeth  revealed 
tubercle  bacilli. 

5.    Diseases  of  the  Alimentary  Canal. 

The  mouth  and  teeth  have  a  very  close  relation  to  the 
rest  of  the  alimentary  canal  both  in  health  and  disease. 
There  are  three  ways  in  which  digestive  disturbances 
occur. 

1.  Insufficient  Mastication.  The  mouth  is  the  place 
where  the  food  should  be  properly  prepared  for  digestion 
by  crushing  it  into  small  pieces  and  mixing  it  with  saliva. 
A  full  set  of  teeth,  especially  bicuspids  and  molars,  is 
necessary  to  accomplish  this.  Lack  of  chewing  surface, 
sore  and  carious  teeth  or  malocclusion  mean  imperfect 
mastication,  and  consequently  increased  and  unnecessary 
work  for  the  stomach.  "While  such  a  condition  leads  to 
various  ills  connected  with  impaired  digestion,"  says 
Hunter,  "it  is  not  the  most  important  relation  of  dental 
diseases  to  general  health." 

2.  Swallowing  of  Bacteria  and  Pus.  Most  serious 
gastric  and  intestinal  disturbances  are  liable  to  result 
from  continuous  swallowing  of  pus  and  bacteria,  which 
are  either  mixed  into  the  food  during  mastication  or 


110  ORAL  ABSCESSES 


reach  the  stomach  between  meals.  Oral  diseases  pro- 
ducing such  conditions  are  numerous  and  common,  oral 
abscesses  discharging  through  sinuses  into  the  mouth, 
stomatitis  and  pyorrhoea  are  of  greatest  importance.  Ill- 
fitting  crowns  and  fixed  bridges,  which  often  cause  most 
contaminating  unsanitary  conditions,  are  also  a  source  of 
gingival  inflammation  and  ulceration. 

The  discharge  from  these  diseased  conditions  is  con- 
tinuously taken  into  the  stomach.  For  a  long  time  the 
acids  of  the  stomach  have  been  looked  at  as  destructive 
to  such  bacteria,  but  Smithies,*  in  a  microscopic  ex- 
amination of  gastric  extracts  from  2,406  different 
individuals  with  "stomach  complaint,"  showed  that 
irrespective  of  the  degree  of  acidity  of  such  gastric 
extracts,  bacteria  were  present  in  eighty-seven  per  cent. 
Hunter  says  there  is  a  limit  to  the  power  of  the  stomach 
to  destroy  such  organisms.  Even  in  health  it  is  never 
complete  and  is  solely  due  to  the  presence  of  free  HC1. 
But  these  powers  become  progressively  weakened,  when 
through  any  cause  an  increased  and  continuous  supply  of 
pus  organisms  is  associated  with  a  diminished  and  contin- 
ually lessening  acidity  of  the  gastric  juice.  During  the 
intervals  between  digestion  the  acidity  of  the  stomach 
reaches  normally  a  low  level  which  also  gives  bacteria  a 
good  chance  to  live  and  multiply  in  the  stomach. 

These  conditions  lead  eventually  to  deeper  seated 
changes  in  the  mucosa  of  the  stomach,  and  also  pass 
through  into  the  intestinal  tract.  They  pass  through  the 
small  intestine,  where  they  also  may  enter  into  the  blood 
stream  to  the  large  intestine  where  they  may  exist  in  large 
numbers.  In  this  fashion  enteritis,  colitis  and  appendi- 
citis may  be  caused. 

3.  Haematogenous  Infections  of  the  Alimentary  Canal 
Due  to  Oral  Foci.  Rosenowf  writes  that  hemorrhages, 
superficial  erosions  and  definite  ulceration  of  the  mucous 
membrane  of  the  stomach  and  duodenum  occur  in  man 
not  infrequently  during  severe  infections.    He  produced 

*  Cited  from  Mayo :  Mouth  infection  as  a  source  of  systemic  disease. 

t  Eosenow:  The  production  of  ulcer  of  the  stomach  by  injection  of  streptococci. 


SECONDAEY  COMPLICATIONS  111 

ulcers  in  the  stomach  or  duodenum,  or  both,  of  eighteen 
rabbits,  six  dogs,  and  in  one  monkey  by  intravenous  in- 
jections of  certain  streptococci,  which  have  a  certain 
grade  of  virulence. 

septic  Many  writers  describe   only  acute   and 

gastritis  chronic  catarrhal  gastritis  and  mention 
bacterial  infection  invading  the  stomach 
from  the  nose  and  accessory  sinuses,  the  throat  and  oral 
cavity  as  one  of  the  causes.  Hunter,  however,  distin- 
guishes a  septic  gastritis  due  to  pyogenic  infection  of  the 
stomach.  The  term  acute  and  chronic  is  principally  used 
to  indicate  a  case  which  is  temporary  in  its  course  or  of 
a  case  which  shows  little  tendency  towards  spontaneous 
recovery. 

Etiology :  Professor  Miller  already  recognized  the  fact 
that  indigestion  may  be  associated  with  foul  mouth,  and 
he  brought  a  charge  against  the  physicians  that  "their 
custom  of  disregarding  dental  diseases  altogether  as  a 
factor  in  pathology  is  as  unjust  to  their  patients  as  it  is 
discreditable  to  their  profession." 

Septic  gastritis  is  caused  by  continuous  swallowing  of 
pus  organisms  such  as  are  discharged  from  oral  abscesses 
with  sinus  and  pyorrhoea  pockets,  infected  tonsils  or 
septic  diseases  of  the  nose.  Not  all  these  bacteria  are  de- 
stroyed, as  has  already  been  explained,  and  the  mucosa 
becomes  eventually  infected,  a  septic  catarrh  is  set  up 
which  is  continuously  sustained  by  influx  of  pyogenic 
bacteria. 

Symptoms :  Clamminess  of  the  mouth,  distaste  of  food, 
coated  tongue  and  bad  taste  in  the  mouth  are  not  so  much 
manifestations  of  gastric  catarrh  as  the  direct  result  of 
oral  sepsis.  The  real  symptoms  are  indigestion,  gastric 
discomfort,  and  nausea. 

Case  XIII.  (Subacute  gastritis.)  Re- 
case  ported   in    Hunter's    "Pernicious    Ane- 

mia," page  231.)  A  lady,  aged  sixty-two 
years,  suffered  from  subacute  gastritis.  The  patient  had 
severe  intermittent  sickness  and  gastric  pain  of  eight 
months'  duration,  necessitating  the  use  of  morphia,  with 


112  ORAL  ABSCESSES 


loss  of  weight  and  increasing  weakness.  Cancer  was  sus- 
pected, but  on  examination  no  sign  of  malignant  disease 
was  found  in  the  stomach,  the  abdomen,  the  rectum  or  the 
uterus.  Constant  complaint  was  made  of  a  bitter  taste 
in  the  mouth,  nausea,  with  loathing  and  distaste  for  all 
food.  The  tongue  was  coated  with  a  dirty  moist  fur. 
The  patient  had  false  teeth  both  in  the  upper  and  lower 
jaws.  The  plates  were  scrupulously  clean,  and  the  gums 
beneath  the  plates  were  perfectly  healthy.  There  were 
four  remaining  teeth,  three  of  them  decayed,  suppurating 
around  the  roots,  with  pus  welling  up  on  pressure.  There 
was  no  other  sign  of  disease.  A  provisional  diagnosis 
was  made  of  gastritis  caused  by  continual  swallowing  of 
pus.  The  roots  were  ordered  to  be  extracted.  A  week 
later,  the  tongue  was  clean,  the  sense  of  taste  returned 
for  the  first  time  for  eight  months,  and  there  had  been 
only  one  attack  of  pain.  In  another  week,  there  was  a 
return  of  the  sickness,  with  vomiting  on  pain  and  slight 
fever.  The  vomit  obtained  two  weeks  later  was  watery, 
with  rusty  flakes  consisting  of  mucous,  fibrin,  catarrhal 
cells,  leucocytes  and  blood,  the  whole  being  loaded  with 
streptococci,  staphylococci  and  a  few  bacilli.  A  diagnosis 
was  made  of  infective  (septic)  gastric  catarrh.  As  a 
local  antiseptic,  three  grains  of  salicylic  acid  were  given 
thrice  a  day,  with  peptonized  milk  as  food ;  counter  irri- 
tation was  applied.  There  was  complete  cessation  of  all 
pain,  and  a  steady  recovery  from  that  time  onward.  The 
patient  gained  weight  rapidly  and  has  since  remained 
well  (two  years). 

Similar  to  septic  gastritis  Hunter  distin- 
enteritis         guishes  a  special  form  of  the  disease, 

namely,  septic  enteritis,  which  is  in  his 
experience  a  very  common  result  of  prolonged  oral  sepsis. 
Etiology:  The  bacteria  which  continuously  enter  the 
stomach  and  escape  destruction  naturally  find  their  way 
into  the  intestine,  where  they  finally  infect  the  thin  epithe- 
lial layer  of  the  mucous  membrane. 

Symptoms :  There  is  more  or  less  abdominal  pain  and 
diarrhea  containing  undigested  food  and  mucous,  whitish 
in  color,  and  sometimes  semi-solid. 


SECOm)ARY  COMPLICATIONS 113 

Case  XIV.  (Case  of  Enteritis.)  Dr. 
caseTRAT,VE  Hunter's  case  reported  in  the  British 
Medical  Journal,  November  19, 1904,  page 
1361.  The  patient,  aged  thirty-seven.  Foul  oral  sepsis ; 
most  intense  gastritis,  enteritis  and  colitis,  chronic  renal 
disease,  pericarditis,  uraemia.  Patient  died,  and  micro- 
scopic examination  of  the  stomach  showed:  intense  gas- 
tritis with  invasion  of  mucosa  by  masses  of  streptococci. 

The  bacterial  invasion  descends  along  the 
coLms>'CmS  almientary  canal  and  may  cause  appen- 
proctitis  dicitis,  colitis  and  proctitis.  The  appen- 
dix is  predisposed  to  infection  on  account 
of  its  poor  blood  supply  (appendicitis  is  most  commonly 
caused  by  the  bacillus  coli,  the  staphylococci  and  strepto- 
cocci). Haematogenous  infection  is  also  supposed  to 
cause  appendicitis,  Poynton  and  Paine  have  caused  it 
experimentally  in  rabbits  with  the  organism  isolated  from 
rheumatic  cases.  If  the  colon  is  involved,  the  disease  is 
called  colitis,  and  if  the  mucous  membrane  of  the  rectum 
becomes  infected,  we  speak  of  proctitis. 

Rosenow's  work  shows  that  in  gastric  and 
gastric  intestinal  ulcers  the  mucosa  is  attacked 

duodenal        from  behind  through  the  blood  stream. 
ulcers  K  is  therefore  a  disease  due  to  haemato- 

genous infection. 
Etiology:  The  bacteria  causing  these  ulcerating  con- 
ditions are  supposed  to  have  a  selective  affinity  for  these 
particular  areas.  Predisposing  factors,  however,  may 
have  a  good  deal  to  do  with  the  localization  of  the  disease. 
Clinicians  have  observed  aggravations  of  symptoms  in 
ulcer  of  the  stomach  following  sore  throat,  and  the  asso- 
ciation of  these  conditions  with  septic  foci  in  the  mouth 
have  been  emphasized  by  various  writers.  Experimental 
evidence  has  been  furnished  by  producing  ulcers  when 
injecting  bacteria  into  the  gastric  artery  by  Rosenow's 
experiments  on  rabbits,  dogs,  and  monkeys  with  the  strep- 
tococcus. Steinharter*  produced  gastric  ulcers  experi- 
mentally in  rabbits  by  injecting  staphylococcus  cultures 

*  See  Bibliography. 


114  ORAL   ABSCESSES 


of  a  special  virulence  and  a  weak  acetic  acid  solution  into 
the  wall  of  the  stomach.  In  the  forty  animals  used  for 
the  experiments  typical  peptic  ulcers  were  produced  vary- 
ing from  one  quarter  of  an  inch  to  one  inch  in  diameter. 
He  concludes:  "In  the  light  of  the  above  results,  it  seems 
possible  that  the  staphylococcus  is  responsible  for  certain 
cases  of  gastric  ulcer  in  human  beings.  If  by  some  means 
(through  an  erosion  or  trauma,  etc.)  a  hyperacid  gastric 
juice  enters  the  tissues  of  a  limited  area  of  the  stomach 
wall,  and  if  the  staphylococcus  of  proper  virulence  finds 
lodgment  there,  it  does  seem  quite  probable  that  the 
necessary  conditions  used  in  producing  the  experimental 
ulcer  would  be  duplicated. 

Symptoms :  About  the  first  symptom  of  intestinal  ulcer 
is  the  occurrence  of  pain  lasting  for  an  hour  or  two  after 
the  ingestion  of  a  hurried  meal,  or  after  the  taking  of  food 
that  needs  unusual  activity  of  digestion.  Hyperacidity 
and  over-secretion,  vomiting,  and  hemorrhages  are  other 
symptoms  of  this  disease.  The  blood  may  be  found  in  the 
vomitus  or  stool. 

Case  XV.  (Gastric  ulcer.)  (One  of  the 
cas1TRAT,VE  cases  reported  by  Hartzel  in  the  Journal 

of  the  National  Dental  Association, 
November,  1915,  page  341.)  The  patient,  a  laborer, 
thirty-one  years  of  age,  of  Irish  descent,  weighing  on  the 
average  160  pounds.  Previous  history,  habits,  and  fam- 
ily history  negative.  His  present  illness  began  in  October, 
1913,  with  heavy  burning  pains  in  the  epigastrium  after 
eating.  In  November  he  noticed  blood  in  the  stools  and 
occasionally  vomited  blood  clots.  He  went  to  the  hospital 
for  two  weeks,  where  he  was  partly  on  a  bread  and  milk 
diet,  and  then  stayed  at  home  for  eight  weeks  before 
going  back  to  work.  After  four  weeks  the  pain  reap- 
peared with  the  same  symptoms.  He  was  admitted  to  the 
University  Hospital  of  Minnesota  (Case  No.  5356),  on 
September  15,  1914.  At  this  time  the  pain  was  absent, 
but  an  area  of  tenderness  was  noted  over  the  stomach. 
He  was  thin,  weak,  unable  to  work,  was  constipated,  with 
blood  occasionally  in  the  stools  and  blood  clots  occasion- 


SECONDABY  COMPLICATIONS 115 

ally  in  the  vomitus.  Physical  examination  showed  him 
fairly  well  nourished,  with  marked  anaemia,  palpable 
cervical  glands,  submerged  tonsils,  had  pyorrhoea  and 
many  old  roots.  The  diagnosis  was  made  as  that  of  gas- 
tric ulcer,  marked  secondary  anaemia,  mitral  insuffi- 
ciency, apical  abscesses  and  pyorrhoea.  Hemoglobin 
35%,  red  blood  cells,  3,500,000,  and  leucocytes,  8,000. 

Between  September  15  and  October  1  oral  infection  was 
eradicated.  All  remaining  upper  teeth  were  extracted, 
also  the  abscessed  lower  molars.  The  remaining  lower 
teeth  were  treated  for  pyorrhoea. 

On  November  2  the  physician  in  charge  made  the  fol- 
lowing note:  "Patient's  condition  has  remarkably  im- 
proved. His  weight  has  increased  twenty-three  pounds. 
There  is  no  abdominal  pain. ' ' 

He  was  discharged  on  November  11,  1914,  greatly  im- 
proved, with  no  other  treatment  than  a  bread  and  milk 
diet  and  the  elimination  of  the  oral  foci. 

He  again  presented  for  examination  in  March,  1915. 
He  had  been  working  and  living  as  a  lumber  man,  eating 
a  full  mixed  diet  and  doing  the  heaviest  kind  of  work,  and 
has  been  perfectly  well  since  leaving  the  hospital.  He 
states  that  for  one  and  a  half  years  before  admission  here, 
he  had  been  troubled  almost  continuously  with  stomach 
symptoms  and  has  never  had  so  long  a  period  of  freedom 
as  this  before.  A  blood  count  at  this  time  showed  the 
hemoglobin  to  be  77%. 

6.    Diseases  of  the  Blood. 

Today  we  know  that  infections  are  never  entirely  local- 
ized. Bacteria,  their  toxins  and  protein  poison,  produced 
during  the  process  of  infection  and  inflammation,  or  both, 
are  always  absorbed  into  the  circulation,  not  only  from 
the  primary  focus,  but  also  from  secondary  lesions. 

The  presence  of  bacteria  and  of  protein  poisons  in  the 
blood  may  cause  diseases  of  violent  and  acute  symptoms, 
or  may  be  very  latent  in  character,  according  to  and  de- 
pending on  the  number,  virulence,  and  species  of  the 


116  ORAL  ABSCESSES 


bacteria,  as  well  as  the  reaction  and  resisting  quality  of 
the  defending  blood  cells. 

septicemia     Septicemia  is  an  acute  general  infection 
of  the  blood  caused  by  bacteremia  which 
occurs  if  living  pyogenic  bacteria  exist  and  multiply  in 
the  blood. 

Etiology :  Septicemia  often  results  from  cases  of  exten- 
sive acute  suppuration  or  from  absorption  of  bacteria  in 
open  wounds.  It  is  predisposed  by  high  virulence  of  the 
bacteria  and  lowered  resistance  of  the  patient.  It  occurs 
especially  after  surgical  interference  in  septic  conditions 
in  patients  with  lowered  resistance,  and  from  persistent 
toxic  and  bacterial  absorption,  as  from  acute  abscesses 
without  outlet  from  the  pus.  In  patients  who  are  feeble 
from  a  long  standing  infection  it  is  therefore  advisable 
not  to  remove  all  foci  at  once,  or  the  result  may  be 
fatal.  The  streptococcus  which  is  found  in  almost  all 
oral  infections  is  the  cause  of  septicemia,  but  also  other 
pyogenic  bacteria  may  produce  the  disease. 

Symptoms:  After  the  inoculation  the  patient  suffers 
from  repeated  chills,  and  the  temperature  rises  to  105°  F. 
The  appetite  is  lost  and  the  patient  apathetic  and  de- 
lirious. The  pulse  becomes  weaker  and  irregular  and  the 
temperature  falls  quickly  before  the  exitus.  Death  usu- 
ally occurs  in  a  few  days,  but  sometimes  the  end  is  drawn 
out  for  several  weeks.  The  diagnosis  of  septicemia  is 
made  by  the  severe  and  rapid  constitutional  symptoms 
and  is  differentiated  from  toxemia  and  sapremia  by  the 
blood  test.  A  blood  culture  should  be  made  at  once, 
using  great  care  to  disinfect  the  patient's  skin.  Blood 
is  withdrawn  from  the  median  basillic  vein  by  means  of 
a  sterile  aspirating  syringe,  and  cultures  are  made  in  the 
ordinary  manner.  If  bacterial  growth  is  obtained,  we  can 
make  a  sure  diagnosis  of  septicemia. 

Treatment :  A  great  deal  depends  upon  prompt,  active 
and  thorough  treatment  of  the  local  lesion.  A  few  hours 
make  a  great  difference  in  the  outcome.  Free  drainage 
should  be  established  by  a  wide  incision ;  hot,  moist,  and 
large  dressings  should  be  applied  and  changed  every  few 


SECONDARY  COMPLICATIONS  117 

minutes.  Saline  infusions  (1000  to  3000  c.c.)  are  ex- 
tremely useful;  the  diet  should  be  regulated;  and  later, 
after  the  infection  has  subsided,  tonics  and  stimulants 
should  be  given. 

pyaemia  Pyaemia  is  an  acute  infection  of  the  blood 

characterized  by  the  presence  of  infected 
emboli  in  the  blood,  which  in  turn  cause  metastatic  ab- 
scesses wherever  they  lodge. 

Etiology :  The  bacteria  causing  the  infection  in  the  pri- 
mary focus  produce  coagulation  of  the  blood.  This  clot 
soon  becomes  infected,  and  portions  of  it  are  broken  off 
and  thrown  into  the  circulation.  It  follows  the  venous 
system,  where  it  may  cause  thrombosis  or  be  carried  to 
the  heart  and  be  distributed  into  any  part  of  the  circula- 
tion. The  streptococcus  is  the  commonest  cause  of  this 
disease,  but  like  septicemia  it  may  also  be  caused  by  the 
bacillus  coli,  staphylococcus,  pneumococcus,  and  bacillus 
typhosus. 

Symptoms:  The  symptoms  are  the  same  as  of  septice- 
mia and  usually  start  with  a  severe  rigor  followed  by 
profuse  sweating.  The  temperature  is  of  intermittent 
character  and  rises  up  to  105  °  F.  Abscesses  usually  make 
their  appearance  after  a  week  and  affect  any  part  of  the 
body.     In  chronic  pyaemia  the  symptoms  are  less  marked. 

Treatment :  The  radical  treatment  of  the  primary  focus 
is  to  be  undertaken  at  once.  The  lesion  should  be  freely 
opened,  the  septic  material  removed  without  disturbing 
the  leucocytic  area,  which  would  allow  absorption  and 
further  contaminate  the  blood  stream.  Establish  free 
drainage  and  irrigate  often.  Anti-streptococcic  serum 
may  be  used  and  also  autogenous  vaccine  as  soon  as  it  can 
be  made.  The  outcome  of  the  disease  depends  upon  the 
resistance  of  the  patient  and  virulence  of  the  bacteria 
and  is  often  fatal. 

Case  XVI.    (Pyemia.)     (Reported  by  C. 
CASETRAT,VE  ^-    Haman,    Wisconsin    Medical    Jour- 
nal,   March,    1903.)      Patient,    a    man 
of    forty    years,    seen    in    consultation    with    Dr.    W. 
E.   Bruner.      An  upper  molar  had  been  extracted  a 


118  ORAL  ABSCESSES 


week  preceding,  the  face  was  swollen  from  an  alveolar 
abscess.  The  right  eye  was  very  prominent.  He  had  a 
high  evening  temperature  of  104  to  106°  F.,  with  morning 
intermissions.  In  a  few  days  the  other  eye  became  promi- 
nent, which  is  quite  characteristic  of  cavernous  sinus 
thrombosis,  and  is  accounted  for  by  the  venous  connection 
between  the  teeth  and  periodontal  structures  and  the  cav- 
ernous sinus.  The  veins  from  the  teeth  empty  into  the 
pterygoid  plexus.  The  pterygoid  plexus  communicates 
with  the  cavernous  sinus  directly  by  means  of  small  veins 
passing  through  the  foramen  Vessalii,  foramen  or  ale  and 
foramen  lacerum  medium,  and  indirectly  through  the 
facial  vein  which  empties  into  the  sinus.  The  diagnosis 
of  sinus  thrombosis  was  confirmed.  The  patient  lived 
about  a  week. 

Toxemia  is  a  term  which  expresses  a  con- 
dition due  to  the  absorption  of  toxins. 
Toxin  in  its  strictest  meaning  is  produced  only  by  a  small 
number  of  bacteria,  as  we  have  already  seen,  such  as  the 
diphtheria  and  tetanus  bacilli.  Generally,  however,  we 
speak  of  toxemia  as  a  condition  which  may  be  caused  by 
the  absorption  of  any  poisonous  substances  originated 
from  bacteria  or  bacterial  activity.  If  the  poison  is  pro- 
duced by  saprophytic  bacteria  which  live  on  dead 
material,  we  speak  of  "sapremia." 

Etiology :  Toxemia  is  due  to  the  absorption  of  poisons 
created  by  bacterial  activity  and  tissue  reaction.  In  true 
toxemia  toxins  only  are  absorbed  from  the  focus,  but  the 
term  is  also  applied  to  all  those  conditions  where  bacteria 
also  have  entered  the  circulation  as  long  as  these  produce 
no  acute  general  infection  (septicemia). 

Foci  which  cause  toxemia  are  found  in  the  intestinal 
tract,  the  genito-urinary  system,  and  nose,  and  adjacent 
sinuses,  the  throat,  and  the  oral  cavity.  Oral  abscesses 
play  the  most  important  role  in  the  mouth,  but  toxic 
absorption  is  also  caused  from  unclean  crown  and  bridge 
work,  stomatitis,  and  pyorrhoea  on  account  of  the  absorb- 
ing quality  of  the  mucous  membrane.  All  lesions  in  the 
mouth  are  caused  or  inhabited  by  the  largest  variety  of 


SECONDARY  COMPLICATIONS  119 

pathogenic  and  saprophytic  bacteria.  They  grow  in  com- 
binations, inhabiting  the  diseased  tissue  simultaneously 
or  acting  at  different  stages  of  the  decomposition,  which 
makes  possible  the  production  of  a  large  variety  of  chemi- 
cal substances,  as  has  already  been  described  in  the  first 
part.  These  poisons  may  have  special  actions  on  certain 
tissues.  It  is  well  known  that  the  diphtheria  toxin,  for 
example,  is  especially  prone  to  attack  the  nervous  system 
and  to  cause  peripheral  neuritis. 

Symptoms:  Toxemia  may  be  very  severe,  beginning 
with  chills,  a  rapid  rise  of  temperature  reaching  104°  F. ; 
there  may  be  anorexia,  headache  and  prostration,  and 
later  delirium,  stupor  or  coma.  In  the  less  severe  or 
chronic  cases,  which  are  of  very  frequent  occurrence,  the 
principal  complaint  is  malaise. 

Malaise  is  a  condition  caused  by  a  certain 
or 'chronic  amoun^  °f  toxin  or  bacteria,  or  both,  en- 
toxemia  tering  the  circulation.    The  disease  is  not 

acute  and  violent  as  in  acute  septicemia 
and  acute  toxemia,  probably  on  account  of  insufficient 
number  and  virility  of  the  bacteria  absorbed,  and  of  the 
small  amount  of  poison  liberated  to  cause  severe  intoxi- 
cation. The  blood  pressure  is  lowered  and  the  symptoms 
are  best  expressed  by  the  complaint  of  the  patient  of  the 
inability  of  doing  mentally  or  physically  the  accustomed 
day's  work.  Slight  exertions  cause  disproportionate 
fatigue.  An  abnormal  amount  of  rest  is  required,  the 
appetite  is  often  poor,  the  skin  has  usually  a  grayish, 
sallow  appearance,  the  lips  lack  the  color  of  health,  there 
is  loss  of  weight,  constipation,  and  benumbed  mental 
activity. 

Treatment :  The  foci  may  not  be  apparent,  and  it  may 
require  a  thorough  search  to  locate  the  lesion  from  which 
the  absorption  takes  place.  It  should  be  remembered  that 
a  very  small  focus  may,  on  account  of  its  persistence  and 
its  chronic  nature,  cause  a  small  but  continuous  infection 
of  the  blood.  The  radical  removal  of  such  foci  is  the  first 
step  in  the  treatment ;  there  is  frequently  more  than  one 
focus  and  it  is  important  to  remove  all  the  septic  con- 


120  OEAL   ABSCESSES 


ditions.  If  the  tonsils  are  diseased,  it  does  not  mean  that 
oral  abscesses  may  not  participate.  The  treatment  of  the 
cause  is  often  sufficient  to  result  in  a  cure ;  in  other  cases, 
it  is  advisable  to  give  tonics  and  stimulants. 

Case  XVII.      (Toxemia.)      Patient,    a 

CASESRAT,VE  yourL£  la(ty?  a  college  student,  consulted 
me  about  a  tooth  which  had  been  unsuc- 
cessfully treated.  She  had  no  symptoms  of  discomfort 
in  her  mouth,  but  upon  questioning,  complained  of  a  tired 
feeling  and  frequent  intermittent  fever  of  about  eight 
months  standing.  A  radiograph  showed  a  lower  six-year 
molar  with  poor  root-canal  filling,  but  no  pronounced 
periapical  destruction.  The  second  bicuspid,  which  is  the 
tooth  in  question,  presented  a  very  large  area  of  lessened 
density  at  the  distal  side  of  the  apex.  The  tooth  was  at 
once  extracted  and  the  bone  curetted.  The  patient  im- 
proved rapidly ;  the  fever  did  not  recur.    (Figure  156.) 

Case  XVIII.  (Toxemia.)  Patient,  a  man  of  middle 
age,  asked  two  years  ago  for  a  careful  examination  of  his 
teeth.  He  complained  of  an  intoxicated  feeling  in  his 
head,  which  manifested  itself  principally  in  the  morning. 
His  ability  to  think  was  greatly  decreased,  smoking  made 
him  ill,  while  before  he  was  able  to  smoke  a  moderate 
amount.  Radiographs  of  his  teeth  showed  abscesses  on 
the  upper  right  incisor,  upper  left  cuspid,  first  and  second 
bicuspid.  I  opened  these  teeth;  a  vile  odor  came  from 
the  canals.  Apiectomy  was  performed  on  the  lateral  in- 
cisor after  the  root  canal  was  properly  treated  and  filled. 
The  cuspid  and  two  bicuspids  I  cleaned  thoroughly  with 
the  sulphuric  acid  method,  and  treated  the  canals  with 
f  ormocresol,  and  ionic  medication.  The  root  canals  were 
filled,  but  the  points  projected  through  the  apical  fora- 
men. During  the  treatment  the  patient  improved 
greatly  and  at  the  end  his  head  felt  perfectly  clear  so 
that  he  could  again  do  his  ordinary  day's  work.  He  also 
said  that  he  was  again  able  to  smoke  without  discomfort. 
After  eight  months  he  came  back  saying  that  the  old 
trouble  recurred  in  a  mild  form.  A  new  radiograph 
showed  the  areas  of  lessened  density  the  same  as  before 


SECONDARY  COMPLICATIONS  121 

the  treatment.  I  amputated  the  roots  of  the  two  bicus- 
pids at  once,  and  later  I  performed  the  same  operation 
on  the  cuspid.  The  patient  reported  an  almost  imme- 
diate change,  and  so  far,  permanent  improvement.  He 
later  told  me  of  another  condition  which  apparently  came 
from  the  teeth.  He  had  the  upper  bicuspid  tooth  treated 
in  Paris  some  time  preceding  and  remembered  distinctly 
that  from  this  date  he  was  afflicted  with  constipation. 
After  the  first  treatment  of  the  teeth  he  got  rid  of  this 
condition  entirely,  and  did  not  need  any  drugs  until  it 
returned  with  the  toxemia.  Again  it  was  permanently 
relieved  after  the  surgical  removal  of  the  abscesses.  The 
interesting  part  about  this  case  is  the  fact  proven  that 
root  canal  treatment  neither  with  antiseptic  nor  ionic 
medication  cured  the  abscess  permanently,  although  the 
treatment  was  thorough  and  much  longer  continued  than 
was  necessary  according  to  general  rules.  The  bacterial 
growth  and  production  of  toxin  was  inhibited  for  a  few 
months,  but  was  only  lying  dormant  until  the  infectious 
process  slowly  recovered.  (Figures  157,  158.) 
anaemia  Anaemia  is  a  reduction  in  the  amount  of 

blood  as  a  whole  or  of  its  corpuscles,  or  of 
certain  of  its  constituents.  There  is  primary  or  idio- 
pathic anaemia  due  to  increased  destruction  due  to  some 
existing  disease.  Among  the  primary  anaemias  belong 
chlorosis,  a  disease  of  young  girls,  and  pernicious  anae- 
mia, the  cause  of  which  is  not  definitely  understood. 
Among  the  secondary  anaemias  belong  acute  and  chronic 
secondary  anaemia.  Hunter  separates  a  special  class 
which  he  calls  septic  anaemia. 

Pernicious  anaemia,  or  Addison's  anae- 
anaemia  m^a'   Hunter   says,   is   characterized  by 

imperfect  action  of  the  blood-making  or- 
gans, the  absence  of  haemalytic  and  bone  marrow  changes, 
and  characterized  by  pigment  changes  in  the  liver,  kidney, 
and  spleen.     The  disease  is  usually  fatal. 

Hunter,  who  has  done  so  much  good  work  on  this  sub- 
ject, thinks  that  a  large  number  of  cases  grouped  as 
pernicious  anaemia  are  really  of  an  infectious  nature  with 


122  ORAL   ABSCESSES 


no  bone  marrow  and  pigment  changes.  The  true  per- 
nicious anaemia,  however,  he  regards  as  a  chronic  infec- 
tive disease  in  which  gastric  disturbances,  altered 
digestion,  absorption  and  auto-intoxication,  as  well  as 
oral  abscesses  and  pyorrhoea  alveolaris,  may  be  a  most 
important  antecedent  and  concomitant,  but  not  the  only 
etiological  factors.  They  precede  the  disease-creating 
conditions  which  permit  the  contraction  of  the  specific 
(haemalytic)  infection  underlying  the  real  characteristic 
features  of  the  disease. 

Septic  anaemia  is  a  term  used  by  Hunter 
anaemia  ^or  a^  cases  °^  secondary  anaemia  which 

are  of  a  septic  infectious  nature.  Many 
of  the  cases  diagnosed  as  pernicious  anaemia,  and  espe- 
cially all  anaemias  comprised  within  Biermer's  definition 
of  progressive  pernicious  anaemia,  show  a  predominant 
septic  factor.  These  are  distinguished  from  pernicious 
or  Addison's  anaemia  by  the  absence  of  haemalytic  and 
bone  marrow  changes  and  absence  of  pigment  changes  in 
kidneys,  liver,  and  spleen. 

Etiology:  Septic  anaemia  is  caused  by  absorption  of 
bacteria  or  the  poisons  of  bacterial  activity  and  may  come 
from  foci  in  the  nose,  sinuses  of  the  oral  cavity  (abscesses, 
pyorrhoea) ,  and  infections  in  the  stomach  and  intestine, 
or  chronic  suppuration  in  any  other  part  of  the  body. 
Prognosis  is  favorable  if  the  cause  is  removed  in  time, 
but  the  disease  may  have  a  severe  and  fatal  course. 

Symptoms :  Dirty  yellow,  anaemic  complexion,  loss  of 
bodily  and  mental  vigor,  with  loss  of  weight.  Not  infre- 
quently there  is  slight  fever.  The  red  blood  corpuscles 
are  reduced,  but  seldom  below  two  millions,  and  haemo- 
globin is  about  forty-five  per  cent,  on  the  average. 

Case  XIX.     (Anaemia.)     (Eeported  by 

caseTRATIVE  T"  B>  Hartzel>  Journal  of  the  Allied  Den- 
tal Societies,  October,  1914,  page  52.) 
This  is  one  case  out  of  four  which  came  under  the  obser- 
vation of  the  writer.  The  patient,  a  Scandinavian  of 
fifty-three  years,  presented  himself  with  a  history  of  his 
illness,  having  started  seven  years  ago  with  slight  at- 


PLATE     XLVII 


Fig.  156 


Fig.  157 


Fig.  158 


Fig.    156. — Radiograph    showing    right    lower    second    bicuspid 
causing  toxemia  in  Case  No.  17. 

Figs.  157  and  158.— Radiographs  of  Case  No.  18,  showing  four 
granulomata. 


PLATE     X  LVI  I  I 


Fig.  159 


Fig.  159a 


Figs.  159  and  159a. 


-Radiographic  plates  of  Case  No.  20.     The  arrows 
indicate  the  granulomata. 


SECONDARY  COMPLICATIONS  123 

tacks  for  a  few  minutes  each  day  of  chills  and  fever, 
followed  by  vomiting.    These  attacks  had  no  relation  to 
his  meals.     Since  this  time  he  had  gradually,  but  inter- 
mittently, grown  weaker.    He  had  trouble  for  some  time 
with  swelling  of  the  limbs  and  with  dizziness.    His  color 
became  pale  and  yellow,  and  he  grew  dull  and  listless. 
When  admitted  to  the  Eliott  Hospital  in  Minneapolis, 
Minnesota,  he  was  weak,  yellow  in  color,  with  constant 
pain  in  his  stomach,  and  seemed  only  dully  conscious. 
The  case  was  diagnosed  by  the  medical  staff  as  pernicious 
anaemia,  with  slight  cardiac  enlargement,  mild  pyorrhoea 
alveolaris  and  rarefaction  about  two  root  ends.    He  was 
put  on  iron  and  arsenites,  and  there  seemed  to  be  but 
little  improvement,  except  a  slight  improvement  in  the 
blood  count,  until  his  mouth  was  put  in  good  condition  by 
the  dental  staff.     Since  that  time  he  has  been  steadily 
improving.     His  consciousness  had  returned  to  normal 
and  his  other  symptoms  have  been  much  improved.     The 
most  striking  picture,  however,  is  presented  by  his  blood 
count,  which  has  steadily  risen  from  900,000  red  blood 
corpuscles  and  15%  haemoglobin  to  2,630,000  red  blood 
corpuscles  and  61%  haemoglobin.    The  only  serious  set- 
back occurred  June  16,  which  was  coincident  with  the 
occurrence  of  a  dental  abscess,  at  which  time  the  haemo- 
globin dropped  back  from  61%  to  55%,  and  the  red  blood 
cells  from  2,630,000  to  1,800,000.    After  extraction  of  the 
abscessed   tooth,    the    last    blood    count    jumped    from 
1,800,000  to  2,500,000,  and  the  haemoglobin  is  the  highest 
it  has  been  since  commencing  his  record,  namely,  65%. 

7.   Diseases  of  the  Heart. 

The  infective  diseases  of  the  heart  are  caused  by  haema- 
togenous  infection  due  frequently  to  the  streptococcus 
viridans,  but  may  also  occur  in  connection  with  typhoid 
fever,  pneumonia,  influenza,  diphtheria,  tuberculosis, 
and  syphilis.  Dr.  Richard  C.  Cabot,  in  an  analysis  of 
six  hundred  successive  and  unselected  cases  of  heart  dis- 


124  ORAL  ABSCESSES 


ease,  found  that  he  could  group  93%  of  these  six  hundred 
cases  under  four  etiological  headings :  1,  Rheumatic,  that 
is,  presumably  streptococci,  46% ;  2,  Nephritic,  19% ;  3, 
Arteriosclerotic,  15%,  and  4,  Syphilitic,  12%.  The 
streptococcic  infections  of  the  heart  have  their  origin  in 
a  large  majority  of  cases  before  the  twenty-second  year. 
It  begins  young,  it  is  essentially  a  chronic  disease,  and  if 
severe  or  progressive,  handicaps  those  afflicted  during 
the  prime  of  life,  and  often  causes  death  before  maturity. 
On  account  of  the  severe  prognosis,  every  effort  should 
be  made  to  eliminate  all  septic  foci  in  the  body  as  a  pre- 
ventive measure,  especially  the  ones  which  are  liable  to  be 
caused  and  harbor  the  streptococcus.  Streptococcic  in- 
fections of  the  tonsils  and  teeth  are  of  very  frequent 
occurrence  in  children  and  form  an  ideal  entrance  for 
disease.  At  this  place  it  is  necessary  again  to  call  atten- 
tion to  the  importance  of  removing  both  tonsilar  and 
dental  foci,  both  on  account  of  the  intimate  relation 
between  these  organs  and  the  danger  of  the  persistence 
from  a  seemingly  unimportant  lesion  after  the  principal 
ones  have  been  removed.  The  temporary  teeth,  especially 
the  temporary  molars,  are  very  often  pulpless  and  ab- 
scessed and  suffered  to  remain  in  the  mouth,  partly 
because  they  cause  no  pain  and  partly  for  orthodontic 
reasons.  It  is,  however,  much  better  to  sacrifice  those 
temporary  teeth  and  take  a  chance  on  the  possibility  of 
malocclusion  rather  than  on  the  possibility  of  heart  in- 
fection and  life  itself. 

The  pericardium,  myocardium,  and  the  valves,  have  the 
same  general  blood  supply  and  therefore  they  are  all 
liable  to  haematogenous  infection  resulting  in  pericar- 
ditis, myocarditis,  and  endocarditis  (valvular  and  mural). 
pericarditis  Pericarditis  is  an  infection  of  the  pericar- 
dium  occurring  in  children  at  an  early 
age.  Its  most  frequent  etiological  factor  is  systemic  in- 
fection from  infections  in  other  parts  of  the  body,  but  it 
also  may  occur  as  a  continuous  infection  from  diseases  of 
the  pleura  as  well  as  the  myocardium. 


SECOm>AEY  COMPLICATIONS  125 

myocarditis  ^e  car(^ac  musculature  very  frequently 
becomes  attacked  by  secondary  infections ; 
it  may  be  due  to  the  streptococcus,  the  gonococcus,  the 
pneumococcus,  or  other  microorganisms.  The  microscope 
reveals  lesions  in  the  heart  muscle  which  explain  cardiac 
irritability  and  later  indications  of  cardiac  distress  from 
infective  diseases. 
-*.r*«^  „  nrMT.r-     Endocarditis  is  the  inflammation  of  the 

ENDOCARDITIS      ,.    .  ,  «    .,       -,  ,  ■,    . 

lining  membrane  ot  the  heart,  and  is 
usually  confined  to  the  valves  (valvular  endocarditis)  and 
rarely  to  the  walls  (mural  endocarditis).  It  is  princi- 
pally caused  by  the  streptococcus  and  especially  by  the 
streptococcus  viridans  (rheumatism),  which  may  be 
transported  from  a  primary  focus,  such  as  the  tonsils, 
abscesses  on  the  teeth,  etc.  The  streptococcus  causing 
endocarditis  grows  best  in  high  oxygen  tension,  and  is 
usually  extremely  virulent.  The  circulating  blood  fur- 
nishes oxygen  in  abundance  and  furnishes  an  ideal  con- 
dition for  an  abundant  vegetative  growth  on  the  valves 
and  walls  of  the  endocardium.  Syphilis,  that  is,  the  spiro- 
chaeta  pallida,  is  another  important  etiological  factor. 
Typhoid,  scarlet  fever,  pneumonia,  influenza,  diphtheria, 
and  tuberculosis  occasionally  involve  the  valves,  but  show 
a  marked  predilection  for  the  myocardium. 

Endocarditis  occurs  in  two  forms:  acute  endocarditis, 
characterized  by  the  presence  of  vegetation  with  loss  of 
continuity  (simple  endocarditis),  or  of  substance  in  the 
valve  tissues  (ulcerative  endocarditis)  ;  chronic  endo- 
carditis is  a  slow  sclerotic  change,  resulting  in  thickening 
and  deformity. 

Treatment :  The  infectious  diseases  of  the  heart  are  of 
a  very  grave  and  often  fatal  nature.  Careful  study  leads 
specialists  to  believe  that  in  a  large  number  of  instances 
heart  disease  in  the  adult  originates  in  childhood,  and  all 
energies  should  be  put  into  the  recognition  and  treatment 
of  these  diseases  in  the  early  stages.  Eustis*  says  that 
endocarditis  in  its  earliest  stages  is  not  surely  recogni- 

*  Endocarditis  in  Children.     Boston  Medical  and  Surgical  Journal,  September 

Zy        19i00 


126  ORAL  ABSCESSES 


zable,  but  that  it  is  important  to  begin  treatment,  in  order 
to  be  effective,  before  a  diagnosis  can  be  made.  This 
means  that  infections  diseases  as  rheumatic  (the  term 
used  in  its  broadest  sense)  attacks,  and  chorea  in  children 
should  be  treated  as  cases  of  acute  endocarditis.  In  these 
cases  of  suspicious  heart  disease,  we  should  remove  septic 
foci,  such  as  diseased  tonsils  or  abscessed  teeth.  It  should 
be  remembered  that  absence  of  pain  in  the  mouth  or 
teeth  is  not  a  sign  of  healthy  condition,  but  on  the  con- 
trary, that  the  most  dangerous  septic  foci,  chronic  ab- 
scesses, are  often  entirely  symptomless  and  unsuspected 
by  the  patient,  and  that  sometimes,  if  the  removal  of 
diseased  tonsils  does  not  give  the  desired  result,  there 
may  be  an  unknown  focus  on  one  or  more  teeth  which 
can  only  be  discovered  by  the  radiograph.  Such  a  focus, 
although  small,  may  be  the  cause  of  persistent  infection. 
In  removing  such  foci  it  is  of  greatest  importance  not  to 
go  about  it  in  a  wholesale  manner;  this  might  result  in 
absolute  harm.  Eustis  reports  a  heart  case  where  a 
severe  relapse  of  chorea  occurred  immediately  after  the 
extraction  of  several  teeth.  The  practice  of  removing 
tonsils,  adenoids,  and  abscessed  teeth,  all  at  one  time,  is 
very  frequently  undertaken  in  order  to  save  the  patient 
repeated  shocks  of  general  anaesthesia,  but  is  poor  policy, 
as  it  is  liable  to  cause  exacerbations  of  the  disease  we  try 
to  cure.  The  foci  should  be  removed  gradually,  the  ton- 
sils separately,  and  the  teeth  one  by  one ;  this  can  be  done 
easily  and  without  causing  great  shock  if  local  anaesthesia 
is  used,  which  is  a  most  excellent  method  for  operations 
in  the  mouth.  It  also  gives  the  operator  a  much  better 
chance  to  curette  and  inspect  the  abscess  cavity,  a  most 
important  part  of  the  operation. 

The  recovery  from  heart  diseases  is  extremely  slow; 
strict  rest  in  bed  for  weeks  or  months  is  almost  univer- 
sally advised  in  these  cases  even  for  several  weeks  after 
the  temperature  and  pulse  have  reached  normal.  This  is 
a  most  difficult  thing  I  find  for  many  dentists  to  under- 
stand ;  they  think  the  patient  should  recover  immediately 
after  the  foci  in  the  mouth  have  been  removed. 


SECONDARY  COMPLICATIONS  127 

Case  XX.      (Subacute  endocarditis.) 

caseTRAT,VE  ^^e  V&tieiat,  a  D°y>  aSe(i  thirteen,  born  in 
Russia.  He  had  been  in  this  country  for 
two  years.  He  had  had  the  measles  when  very  young  and 
scarlet  fever  some  five  years  before  coming  to  this  coun- 
try.    He  never  had  had  any  sore  throat. 

Seven  months  ago  he  started  to  have  pain  in  the  joints, 
mostly  in  the  shoulder  region,  associated  with  fever. 
Shortly  afterwards  he  complained  of  pain  over  the  pre- 
cardia  and  of  dyspnea  upon  exertion.  He  was  kept  in 
bed  except  for  meals. 

Physical  examination  showed  lungs  negative;  heart, 
apex  visible  and  palpable  in  fifth  interspace,  11  cm. 
from  the  midst ernum.  Over  the  apex  was  felt  a  distinct 
presystolic  thrill.  Sounds  of  a  fair  quality  but  rapid. 
At  mitral  area  is  heard  a  presystolic  murmur.  Over  aorta 
is  a  diastolic  murmur  and  over  pulmonic  area  is  a  systolic 
murmur.  Abdomen  is  full,  soft,  and  tympanitic 
throughout.  No  masses  or  tenderness.  Knee  jerks  pres- 
ent. No  glands  in  neck,  axilla,  or  groin.  Pulse  equal, 
regular,  of  waterhammer  variety.  Capillary  pulse 
present. 

Patient  was  admitted  to  the  Robert  B.  Brigham  hos- 
pital on  November  6.  Temperature  100.6°  F. ;  pulse, 
140 ;  respiration,  28 ;  blood  pressure,  125-80.  He  was  put 
on  a  light  diet  and  kept  in  bed.  I  ordered  X-rays  taken 
of  his  teeth,  which  showed  shadows  representing  granu- 
lomata  at  the  roots  of  the  two  lower  first  molars  and  one 
upper  first  molar.  I  extracted  the  upper  first  molar  on 
December  11,  and  the  right  lower  first  molar  on  December 
14,  both  under  local  anaesthesia.  Cultures  from  the 
upper  molar  revealed  a  streptococcus  and  staphylococcus 
infection.  From  the  lower  molar  a  pure  streptococcus 
infection  was  demonstrated.  On  December  23  a  slight 
downward  tendency  of  temperature  was  reported,  the 
pulse  still  being  variable.  He  received  vaccine  treatment 
beginning  January  10,  1915,  which,  however,  did  not 
improve  his  condition.  On  February  3,  the  third  six-year 
molar  was  extracted,  and  yielded  a  streptococcus  culture. 


128  ORAL  ABSCESSES 


The  patient  improved  materially  after  this  and  was  ad- 
vised to  have  his  tonsils  out,  as  they  were  enlarged,  but 
left  the  hospital  on  February  28  at  his  father's  request. 
He  was  again  examined  at  the  hospital  in  June,  1916. 
He  was  greatly  improved :  no  temperature,  better  pulse, 
is  able  to  go  about  and  to  attend  school.  Regurgitation 
and  mitral  stenosis  are  still  present  and  will  probably  re- 
main as  permanent  defects.     (Figure  159.) 

8.    Affections  of  the  Nervous  System. 

Nerve  affections  due  to  oral  conditions  are  either  local, 
remote,  or  general.  The  local  conditions  arise  from 
direct  infection  of  the  branches  of  the  maxillary  or  man- 
dibular division  of  the  fifth  nerve  by  septic  condition,  or 
are  caused  by  pressure,  such  as  is  frequently  caused  by 
impacted  and  unerupted  teeth.  The  pain  is  usually 
referred  to  other  branches  of  the  fifth  or  to  communi- 
cating nerves  which  may  result  in  complaints  in  other 
organs  such  as  the  ear  and  eye,  where  not  infrequently 
aural  or  ophthalmic  disturbances  are  produced  by  the 
referred  irritation.  These  conditions  have  already  been 
described  under  their  respective  headings.  If  nerves  in 
other  parts  of  the  body  are  infected,  we  speak  of  remote 
infection,  and  if  a  large  number  is  involved,  we  speak  of 
general  nerve  infection.  The  two  latter  conditions  are 
caused  by  haematogenous  infection  or  intoxication.  The 
bacteria  and  poisons  created  by  bacterial  activity  or  the 
latter  alone  are  absorbed  from  the  primary  focus  and 
certain  toxins  are  thought  to  have  a  special  affinity  for 
the  nervous  system.  The  poisoned  blood  irritates  the 
nerves  and  causes  certain  disturbances  such  as  neuritis, 
chorea,  insomnia,  and  mental  depression. 
neuritis  Neuritis  is  an  inflammation  of  the  nerve 

trunks ;  it  may  be  in  a  single  nerve  local- 
ized, "or  involving  a  large  number  of  nerves,' '  called 
general  or  multiple  neuritis. 

Etiology :  Localized  neuritis  is  usually  caused  by  cold, 
traumatism,  or  extension  of  inflammation  from  neigh- 


SECONDAEY  COMPLICATION'S  129 

boring  parts.  This  condition  is  of  frequent  occurrence 
in  the  mouth.  Alveolar  abscesses,  or  impacted  teeth, 
maxillary  sinusitis,  and  osteomyelitis  often  involve  in- 
flammation of  parts  of  the  second  or  third  division  of 
the  fifth  nerve.  Postoperative  pains  after  operations  on 
the  jaws  are  also  well  known  and  are  due  to  traumatic 
injury  of  or  continuous  traumatic  inflammation  of  the 
nerves. 

General  neuritis  has  a  very  complex  etiology :  organic 
poisons,  as  alcohol,  ether,  lead,  arsenic,  mercury,  etc.,  and 
poisons  caused  by  infections,  such  as  streptococcus,  infec- 
tions, diphtheria,  typhoid  fever,  smallpox,  scarlet  fever, 
syphilis,  and  others. 

Hunter  and  other  authors  think  that  oral  sepsis  plays 
a  great  role  in  the  etiology  of  toxin  neuritis.  Hunter* 
gives  three  well-studied  cases  of  typical  general  neuritis 
prevailing  for  many  years  (Case  3  for  fourteen  years), 
and  in  all  cases  there  resulted  immediate  improvement 
from  the  removal  of  the  septic  oral  conditions. 

Symptoms :  In  localizing  neuritis  there  is  pain  of  a  bor- 
ing or  stabbing  character  felt  in  the  course  of  the  nerve 
and  in  the  parts  supplied.  In  general  neuritis  there  is 
no  constant  intense  pain  in  the  nerves,  but  there  is  numb- 
ness and  tingling  in  the  hands  and  arms  or  part  supplied, 
a  so-called  paresthesia,  which  is  often  described  as  the 
"pins  and  needles"  sensation.  There  may  also  be  altera- 
tions in  the  muscular  power  and  abolition  of  deep  reflexes. 
illustrative  Case  XXI.  (Local  neuritis.)  The  pa- 
case  tient,    a   woman    of    about    thirty-seven 

years,  complained  of  local  neuritis  in  the 
lower  jaw.  An  X-ray  plate  was  taken  and  showed  a  large 
area  of  lessened  density  about  a  root  in  the  lower  jaw. 
The  inflammatory  process  involved  in  this  case  the  in- 
ferior alveolar  nerve  and  was  the  direct  cause  of  the 
neuritis.  After  removal  of  the  root  and  curettage,  fol- 
lowed by  occasional  treatment,  the  condition  disappeared 
^completely.     (Figure  160.) 

*  Hunter:  Pernicious  anaemia,  pp.  303-305. 


130  ORAL   ABSCESSES 


trifacial  Neuralgia  is  a  pain  in  a  nerve  or  nerves 
neuralgia  °^  radiating  character.  Trigeminal  neu- 
ralgia attacks  mostly  only  one  branch  of 
the  nerve,  but  in  rarer  cases  two  or  all  divisions  may  be 
involved.  It  is  characteristic  for  the  disease  that  no 
inflammatory  conditions  occur  in  the  part  where  the  pain 
is  located. 

Etiology:  The  cause  of  trigeminal  neuralgia  is  fre- 
quently of  obscure  character  and  often  cannot  be  located 
even  after  the  most  painstaking  search.  It  is  said  to  occur 
from  general  and  local  causes.  The  general  causes  are  a 
result  of  toxemia  such  as  produced  by  infectious  diseases. 
The  local  causes  are  more  important.  They  may  be  due 
to  diseases  of  the  eye,  middle  ear,  nose  and  accessory 
sinuses,  or  especially  the  oral  cavity  and  teeth. 

The  diseases  of  the  oral  cavity  most  commonly  cause 
trifacial  neuralgia.  Pulpstones  or  nodules  often  occur 
in  the  pulp  chamber  of  a  tooth,  causing  pressure  upon  the 
nerve  fibres  of  the  pulp.  Impacted  and  unerupted  teeth 
are  also  an  important  factor.  The  pressure  exerted  by  a 
developing  tooth  which  grows  in  a  wrong  direction  may 
be  extremely  great  and  sometimes  even  causes  absorption 
of  parts  of  the  permanent  tooth  which  stands  in  its  way, 
even  exposing  its  nerve.  Pieces  of  alveolar  process  are 
sometimes  fractured  after  extraction  and  escape  dis- 
covery, or  such  pieces  or  ends  of  roots  may  be  forced  into 
the  cancellous  part  of  the  bone  and  cause,  especially  in  the 
lower  jaw  on  account  of  the  mandibular  canal,  pressure 
upon  the  nerve.  Abscesses  on  unerupted  and  impacted 
teeth  and  chronic  abscesses  in  general  may,  besides  being 
a  focus  from  which  toxic  absorption  takes  place,  be  the 
cause  of  trigeminal  neuralgia.  They  usually  give  no  local 
discomfort,  but  may  be  causing  irritation  and  inflamma- 
tion of  branches  of  the  fifth  nerve,  causing  in  turn  a  reflex 
neuralgic  condition. 

Synrptonis :  The  pain  many  times  is  only  a  slight  and 
bearable  one,  but  in  other  cases  it  is  of  most  excruciating 
character.  Some  patients  have  a  continuous  mild  pain 
with  severe  attacks  at  irregular  intervals.    The  interim, 


PLATE      XLIX 


Pig.  160 


Fig.   160. — Eadiographic  plate  of   Case  No.   21,  showing  a  large  osteo- 

myelitic  area  caused  by  the  root  which  remained  under  a  bridge.     The 

diseased  area  extends  into  the  mandibular  canal  causing  neuritis  of  the 

inferior  alveolar  nerve. 


PLATE      L 


Fig.  161 


Fig.  162 


Fig.  161. — Eadiograph  of  lower  molar  with  cavity  beneath  the  gum   (dark  area  around 

the  filling)   of  Case  No.  22. 

Fig.    162. — Kadiographie    plate    showing    impacted    lower    third    molar    which    caused 

neuralgia  in  Case  Xo.  23. 


SECONDARY  COMPLICATION'S 


131 


during  which  the  patient  is  either  free  of  pain  or  where 
there  is  only  a  dull  aching,  may  last  minutes,  hours,  or 
days.  The  attacks  sometimes  are  of  such  terrible  charac- 
ter that  the  patient  is  tempted  to  commit  suicide. 

The  attacks  occur  either  spontaneously  or  may  be  in- 
duced by  movements  of  the  mouth,  washing  of  the  face, 
or  touching  the  lips  or  cheek  with  the  fingers. 

Diagnosis :  Diagnosis  of  trigeminal  neuralgia  requires 
the  most  painstaking  search  for  general  as  well  as  local 
causes.  It  is  principally  a  process  of  elimination  of  one 
possible  cause  after  the  other.  The  use  of  the  radio- 
graph is  imminent  for  examination  of  the  oral  cavity. 
Plates  should  be  taken  first  to  make  sure  that  there  are 
no  impacted,  unerupted,  or  supernumerary  teeth  or  odon- 
tomas in  remote  parts  of  the  maxillary  or  mandibular 
bones.  The  plates  also  give  us  a  general  idea  about  the 
teeth.  Films  from  different  angles  should  then  be  taken 
of  all  the  teeth  for  a  more  detailed  diagnosis,  and  only  the 
very  best  negatives  are  good  enough  to  ascertain  the  pres- 
ence or  absence  of  abscesses  and  pulpstones. 

Dr.  Henry  Head  believes  that  neuralgic  pains  resulting 
from  teeth  have  definite  areas  of  reference  in  relation  to 
the  tooth  involved.  These  areas  have  been  ascertained  by 
gently  pinching  the  loose  skin,  and  if  the  right  spot  is 
touched,  there  is  often  a  distinct  exacerbation  of  pain 
from  the  tooth.  The  following  table  is  from  Behan's 
book  on  "Pain." 


Tooth 

Reference  Area 

Maxill. 

Incisors 

Fronto  nasal  region 

Maxill. 

Cuspid 

Naso  labial  region 

Maxill. 

First  Bicuspid 

Naso  labial  region 

Maxill. 

Second  Bicuspid 

Temp  '1  or  maxillary 

Maxill. 

First  Molar 

Maxillary  region 

Maxill. 

Second  Molar 

Mandibular  region 

Maxill. 

Third  Molar 

Mandibular  region 

Mand. 

Incisors 

Mental  region 

Mand. 

Cuspid 

Mental  region 

Mand. 

First  Bicuspid 

Mental  region 

Mand. 

Second  Bicuspid 

Hyoid  or  mental 

Mand. 

First  Molar 

Hyoid                   )  Also  in  ear  and  just  behind 

Mand. 

Second  Molar 

Hyoid                   >  angle  of  jaw  and  tip  of 

Mand. 

Third  Molar 

Sup.  Laryngeal  )  tongue  on  same  side. 

132  ORAL   ABSCESSES 


Treatment :  Treatment  of  neuralgia  consists  of  removal 
of  the  cause  and  treatment  of  the  symptoms.  In  cases  of 
obscure  persistent  nature,  alcohol  injection  into  the  main 
trunks  or  the  Gasserian  ganglion  are  recommended.  Neu- 
rectomy of  the  terminal  branches  or  of  the  whole  second 
or  third  division  is  advocated  by  the  believers  in  the 
surgical  methods,  and  as  a  last  resort  the  removal  of  the 
Gasserian  ganglion. 

Case  XXII.  (Trifacial  neuralgia.)  Pa- 
casesRAT,VE  tient>  Mrs.  S.,  was  referred  to  me  for 
radiographic  examination  to  find  the 
cause  of  an  obscure  neuralgia,  which  was  referred  to  the 
right  upper  side  of  the  jaws.  A  diseased  condition  of  the 
bone  in  the  upper  jaw  was  suspected  by  her  dentist.  The 
radiograph,  however,  revealed  an  obscure  pus  condition 
about  the  root  of  the  lower  second  molar  concealed  by  the 
gum,  causing  necrosis  of  the  root.  The  extraction  of  the 
lower  molar  stopped  the  neuralgia  entirely.  (Figure  161.) 

Case  XXIII.  (Trifacial  neuralgia.)  Patient,  a  young 
lady,  complained  of  faceaches  on  the  left  side,  which 
sometimes  were  very  severe  and  interfered  with  her 
studies.  X-ray  showed  an  impacted  lower  wisdom  tooth 
as  well  as  abscesses  on  both  ends  of  the  first  molar.  I 
extirpated  the  impacted  tooth,  extracted  the  first  molar, 
and  curetted  the  abscess  cavities.  The  patient  made  quick 
recovery  and  has  been  free  of  pain  ever  since.  (Figure  162.) 
~..^_~.  Chorea,  or  St.  Vitus 's  Dance,  is  a  disease 
chiefly  affecting  children,  characterized  by 
irregular,  involuntary  contraction  of  the  muscles,  and  a 
marked  association  with  acute  endocarditis  and  rheu- 
matism. 

Etiology:  The  disease  is  most  common  in  children  be- 
tween the  age  of  five  and  fifteen.  Fright,  injury,  and 
mental  worry  are  named  as  etiological  factors ;  the  prin- 
cipal cause,  however,  seems  to  be  of  an  infectious  nature. 
It  has  already  been  said  that  chorea  is  closely  related  to 
endocarditis  and  rheumatism,  which  diseases  we  know  to 
be  due  to  streptococcemia,  thanks  to  our  modern  under- 
standing enlightened  by  the  splendid  work  of  Rosenow. 


SECONDAEY  COMPLICATIONS  133 

The  foci  which  are  looked  for  in  the  streptococcus  infec- 
tions (arthritis,  endocarditis)  are  therefore  also  possible 
foci  for  chorea,  and  practical  experience  confirms  this 
supposition.  Eustis*  mentions  two  relapses,  one  of  arth- 
ritis and  one  of  chorea  following  tonsilectomy,  and  also 
reports  another  case  where  a  severe  relapse  of  chorea 
followed  immediately  after  the  extraction  of  several 
teeth.  These  relapses  are  due  to  an  increased  amount  of 
bacteria  absorbed  from  the  unprotected  wound  and  again 
teaches  us  to  remove  such  foci  one  by  one  with  an  interval 
of  several  days  between  each  extraction  or  operation. 

Case  XXIV.  (Chorea.)  (Eenorted  by 
caseTRA  M'  T'  Schamberg,  Journal  of  the  Allied 

Dental  Societies,  December,  1915.)  A 
young  girl,  about  fifteen  years  of  age,  was  sent  to  the 
hospital  with  the  following  complications  of  diseases: 
chorea,  muscular  rheumatism,  and  a  valvular  lesion  of  the 
heart.  She  was  observed  in  the  medical  ward  and  treated 
for  some  time  without  material  improvement.  When  she 
was  finally  sent  to  Dr.  Schamberg's  clinic,  the  jactitation 
and  convulsive  movements  of  her  body  almost  interfered 
with  a  thorough  examination  of  her  mouth.  Yet,  staring 
us  in  the  face  was  a  gold  crown  upon  an  upper  front  tooth. 
An  X-ray  was  made  of  this  part  and  an  infection  detected. 
The  removal  of  the  tooth  and  curettage  of  the  bone  was 
promptly  followed  by  an  improvement  in  the  chorea,  and 
at  the  end  of  several  weeks  the  patient  walked  with 
scarcely  any  evidence  of  the  disease.  There  was  likewise 
such  a  pronouncd  improvement  in  her  other  conditions 
that  she  was  considered  well  enough  to  be  dismissed  from 
the  hospital. 

Mental  depression  and  melancholia  are 
M^bAi^£iJ-°h,A  diseases  or  perhaps  symptoms  of  a  more 

AND  MENTAL  ,  -,       x  \  -vm    i       i. 

DEPRESSION    or  less  obscure  nature.    While  it  seems  a 
far  cry  from  oral  infections  to  mental  dis- 
eases, we  have  reliable  reports  from  sincere  men  who 
have  seen  profound  depression  and  melancholy  disappear 

*Ettstis:    Endocarditis   in    Children.     Boston   Medical    and   Surgical    Journal, 
September  2,  1915. 


134  ORAL   ABSCESSES 


after  the  treatment  or  surgical  removal  of  septic  foci  in 
the  mouth.  Such  cures  are  convincing  arguments  that 
chronic  intoxications  from  septic  foci  are  some  of  the  etio- 
logical factors  in  these  conditions. 

Case  XXV.  (Mental  depression  with 
CASE  oral  sepsis  as  an  important  factor.)     (Re- 

ported by  C.  Burns  Graig.)  The  patient 
a  woman  aged  fifty-nine,  well  preserved,  and  of  more 
than  average  mentality.  She  came  from  a  long-lived, 
non-nervous  stock.  The  father  died  three  years  ago,  the 
mother  two  years  ago.  During  the  week  of  the  mother's 
death  she  had  a  nasal  operation.  Soon  after  this,  finan- 
cial losses  caused  considerable  worry.  The  patient  con- 
tinued in  reasonably  good  health  for  over  a  year.  At 
this  time  she  went  to  a  fashionable  sanitarium,  more  as  a 
pleasure  resort  than  for  treatment.  While  there,  she 
began  to  have  attacks  of  dizziness.  A  physician  told  her 
she  had  mild  heart  disease  and  prescribed  Nauhehn  baths. 
After  she  had  taken  eleven  baths  a  nervous  breakdown 
began. 

When  first  seen,  the  patient  was  greatly  depressed  and 
nearly  always  in  a  state  of  agitation,  at  other  times  she 
spoke  in  a  mournful  tone  without  being  able  to  give  the 
exact  cause  of  her  depression.  She  said  she  was  con- 
vinced she  would  not  recover. 

Physical  examination  was  entirely  negative  except 
pulse  of  100  and  condition  of  her  teeth.  Radiograms 
showed  two  abscesses  on  the  roots  of  crowned  teeth  and 
a  collection  of  pus  beneath  a  faulty  bridge.  The  stools 
when  examined  proved  normal,  except  slight  evidence  of 
catarrhal  colitis.  Haemoglobin,  78%.  Red  blood  cells, 
4,869,000.  White  blood  cells,  6,500 ;  differential  showed 
mild  increase  in  the  lymphocytes.  Urine  normal.  A  test 
breakfast  showed  diminution  in  the  hydrochloric  acid  con- 
tent. A  serum  Wasserman  was  negative  and  the  spinal 
fluid  was  normal  in  every  respect. 

A  week  of  tonic  measures  was  without  noticeable  im- 
provement. It  was  then  decided  to  have  the  bridge  work 
removed  and  the  abscesses  cured.    During  the  following 


SECONDABY  COMPLICATIONS  135 

week  the  cloud  began  to  lift  and  the  patient  began  to  have 
moments  of  better  humor,  and  saw  some  possibility  of 
looking  at  the  brighter  side  of  things.  She  was  then  sent 
to  the  country  for  two  weeks  from  whence  she  returned 
in  a  comparatively  happy  state  of  mind. 

Case  XXVI.  (Melancholia.)  (Reported  by  Van 
Doom,  Dental  Cosmos,  June,  1909.)  The  patient,  a  young 
lady,  was  referred  to  Dr.  Yan  Doom  as  a  case  of  melan- 
cholia. The  patient  had  as  little  cause  for  mental  depres- 
sion as  one  could  possibly  imagine,  of  which  she  was  as 
well  aware  as  the  doctor.  She  had  wealth,  friends,  a 
beautiful  home,  and  the  education  and  culture  that  should 
go  with  such  a  happy  environment.  Examination  of 
the  mouth  revealed  nothing  serious.  Radiographs  taken 
by  Dr.  Lodge  revealed  a  number  of  teeth  with  areas  of 
absorption  about  their  apices,  of  the  existence  of  which 
she  had  not  the  slightest  idea.  Some  of  the  teeth  were 
extracted,  others  could  be  saved  by  treatment.  Within 
a  short  time  after  the  septic  foci  in  the  mouth  had  been 
removed,  the  patient  was  in  normal  condition.  She  had 
no  recurrence  of  her  melancholia  up  to  the  time  of  the 
essay  (about  one  year). 

9.    Diseases  of  the  Joints. 

ACUTE  Acute  infectious  arthritis,  or  rheumatic 

infectious  fever?  is  an  acute  infection  of  the  joints 
a  dtuditic  to  focal  disease.  In  children,  carditis  and 
chorea  otten  occur  simultaneously;  in 
adults,  the  systemic  infection  involves  the  heart  less  fre- 
quently. 

The  disease  usually  starts  with  irregular  pains  in  the 
joints  and  slight  malaise.  There  is  slight  chilliness,  the 
fever  rises  quickly  and  within  twenty-four  hours  the 
disease  is  fully  manifest.  Temperature  between  102  and 
104°  F.  Pulse  soft  and  usually  above  100.  The  affected 
joints  are  painful  to  move,  soon  become  swollen  and  hot 
and  present  a  reddish  flush.  The  disease  is  seldom  limited 
to  a  single  articulation  and  the  joints  are  usually  attacked 


136    ORAL   ABSCESSES 

successively.  The  course  of  the  disease  is  extremely  vari- 
able and  depends  whether  there  are  also  cardiac  (endo- 
carditis, myocarditis,  pericarditis),  pulmonary  (pneu- 
monia and  pleurisy),  and  nervous  (chorea,  meningitis, 
polyneuritis,  coma)  affections. 

Etiology:  The  newer  methods  of  bacterial  culture 
(Eosenow)  have  proved  the  presence  of  infectious  organ- 
isms in  the  joint  fluid,  in  the  synovial  membrane  and 
proximal  lymphnodes  where  it  may  always  be  found  dur- 
ing the  height  of  the  disease.  The  organisms  belong  to 
the  diplococcus,  streptococcus  class.  The  focus  is  prin- 
cipally found  in  the  throat  (tonsils),  nose,  and  accessory 
sinuses,  and  the  oral  cavity. 

Case  XXVII.  (Acute  Infectious  Arthritis.)  Patient, 
a  man,  about  thirty-four  years  of  age,  was  sent  to  me  for 
treatment.  Had  had  measles  followed  by  mumps,  but  no 
other  childhood  diseases.  A  month  before  consulting  me 
he  had  rheumatic  swellings  and  pain  in  the  knees.  The 
shoulders  were  next  attacked,  and  after  a  short  time  all 
the  large  joints  became  involved.  He  took  electric  baths 
but  did  not  improve. 

He  was  able  to  walk  only  with  crutches.  He  showed 
me  radiographs  which  had  been  taken  of  his  teeth.  There 
were  areas  of  lessened  density  on  the  right  upper  central 
incisor  and  the  left  upper  first  molar.  The  broach  which 
the  dentist  had  inserted  into  the  root  canal  extended 
directly  into  the  antrum  and  a  frontal  plate  of  both  an- 
tra showed  an  opaque  area  on  the  left  side.  I  operated, 
opening  through  the  canine  fossa ;  there  was  a  large  ab- 
scess at  the  floor  of  the  antrum.  I  extracted  the  trouble- 
some molar  and  removed  by  curettage  the  diseased  bone 
and  abscessed  areas.  The  antrum  was  washed  daily. 
Apiectomy  was  then  performed  on  the  central  incisor. 

The  patient  suffered  an  exacerbation  in  the  knee  joint 
and  had  to  stay  in  bed  for  three  days.  After  a  week  he 
started  to  improve  gradually  and  after  seven  weeks,  when 
the  antrum  had  healed,  he  was  entirely  rid  of  arthritis. 
He  walked  into  my  office  without  difficulty ;  his  joints  were 


PLATE      LI 


Fig.  163 


Fig.  164 


Fig.  165 


Figs.  163,  164  and  165.— Radiographs  of  Case  No.  27.     There  is 

an  abscess  on  the  upper  central  incisor  and  upper  first  molar, 

which  infected  the   antrum   causing  acute   arthritis  of   all  the 

joints. 


PLATE      LI 


Fig.  166 


Fig.    167. 


Fig.  167 

Fig.  166.— Normal  Land. 
-Hypertrophic  Arthritis.      Note  the  bo.iy  overgrowth  of  many  of  the  phalangeal  joints, 
especially  the  terminal  of  the  first  and  fifth  phalanges. 


SECONDARY  COMPLICATIONS 


normal.  He  received  no  general  treatment  while  I  took 
care  of  him,  and  the  improvement  in  the  condition  of 
the  joints  was  wholly  due  to  the  removal  of  the  infectious 
focus.     (Figures  163  to  165.) 

Hypertrophic  arthritis  is  the  term  used 
hypertro-  by  Goldthwaite,  Painter,  and  Osgood  for 
arthritis  those  cases  in  which  the  chief  lesion  is 
an  outgrowth  of  bone  in  or  very  near  the 
joint,  but  without  destruction  of  joint  tissue  as  a  charac- 
teristic or  important  change.  Most  writers  agree  to 
classify  these  cases  as  hypertrophic,  except  Billings,  who 
would  deny  this  condition  a  class  by  itself,  placing  it  in 
the  group  with  atrophic  arthritis  as  a  result  of  joint 
infection.     (Figure  167.) 

It  is  a  disease  of  the  latter  half  of  life.  There  is  usu- 
ally a  history  of  trauma,  or  static  disturbances.  The 
disease  does  not  show  a  tendency  to  steady  progression. 
There  is  no  true  ankylosis,  motion  is  limited  only  by 
interference  of  the  exostoses.  The  X-ray  shows  the  pres- 
ence of  osteophytic  outgrowths  and  marked  marginal 
lipping  of  the  joints. 

Etiology:  Painter,  who  also  recognizes  the  type  of 
hypertrophic  arthritis,  believes  it  is  not  due  to  infection, 
but  to  a  combination  of  trauma  and  faulty  metabolism. 
gouty  Glouty  arthritis  should  not  be  confused 

arthritis  with  true  gout,  for  many  of  the  charac- 
teristics are  lacking.  It  is  a  disease  of  the 
metabolism  which  may  attack  any  damaged  joint.  It 
derives  its  name  from  the  fact  that  the  bones  show  the 
small  pouched  out  spots  called  " Bruce 's  nodes,"  which 
are  also  found  in  true  gout.     (Figure  168.) 

Painter  divides  the  chronic  infectious 
chronic  IN-  type  of  arthritis  into  infectious  and  atro- 
A^.pQlpH'^ANDphic.  It  has  been  established  that  the 
arthritis  infectious  group  is  found  in  earlier  life, 
while  the  atrophic  type  is  seen  in 
persons  of  older  age.  In  the  Robert  B.  Brigham  Hos- 
pital Painter  classified  twenty-five  cases  and  showed  that 
the  average  age  of  the  infectious  type  is  thirty-two  years, 


138  ORAL   ABSCESSES 


of  the  atrophic  type  forty-nine  years.  "It  seems,  there- 
fore, logical  to  suppose,"  says  Lawrence,  "that  atrophic 
and  infectious  arthritis  are  but  different  stages  of  the 
same  process. ' '  The  chronic  infectious  type,  which  occurs 
in  early  life,  is  called  Still's  disease  in  children. 

Etiology :  Chronic  infections  and  their  sequel,  atrophic 
arthritis,  are  much  more  common  and  more  serious  than 
the  hypertrophic  form.  The  two  main  causes  of  these 
two  types  are  now  generally  held  to  be  autointoxication 
and  infection.     (Figures  169  and  170.) 

Autointoxication  is  by  some  writers  believed  the  etio- 
logical factor,  because  many  investigators  (Phillip,  Cole, 
Beattie,  and  others)  failed  entirely  to  demonstrate  bac- 
teria in  the  diseased  joints.  The  toxin  material  may 
come  from  any  part  of  the  body  and  may  be  due  either 
to  continuous,  persistent  bacterial  activity  in  some  focus 
discharging  toxins  into  the  blood  (toxemia),  or  to  meta- 
bolic or  digestive  derangements. 

Bacterial  infection  of  the  joint  tissue  is  believed  to  be 
the  cause  by  other  writers,  S chillier,  Poynton,  Paine,  and 
before  all,  Rosenow  isolated  three  organisms  belonging  to 
the  streptococcus  pneumococcus  group  from  the  joints. 
Each  of  these  organisms  is  convertible  into  the  other  types 
by  cultural  methods.  These  bacteria  have  a  characteristic 
low  grade  virulence  and  grow  best  in  a  low  oxygen  tension 
and  even  grow  anaerobically.  Such  a  condition  is  found 
in  the  infected  joints  caused  by  the  method  by  which  the 
bacteria  invade  the  tissue ;  the  vessels  supplying  the  joints 
are  closed  by  endothelial  proliferation  at  the  site  and 
stimulated  by  the  bacterial  embolus.  Injected  into  animals 
they  produce  arthritis,  endocarditis,  pericarditis,  myosi- 
tis, and  myocarditis.  Steinharter*  undertook  such  animal 
experiments,  injecting  staphylococcus  cultures  into  rab- 
bits and  dogs  intravenously.  The  material  used  was  pre- 
pared by  suspending  an  agar  slant  culture  in  about  10  c.c. 
of  normal  salt  solution.  The  usual  dose  of  such  an  emul- 
sion was  1  c.c.  for  a  rabbit  and  3  c.c.  for  a  dog.  The  re- 
sults as  shown  by  the  published  protocols,  indicate  that 
the  staphylococcus  is  apt  to  localize  in  the  joints  and  pro- 

*  See  Bibliography. 


PLATE     LI  I 


Fig.    168.— Gouty   Arthritis.     Note   hypertrophic   changes    of   the   phalangeal    joints    and   the 

small  areas  having  a  pouched  out  appearance  just  posterior  to  the  distal  end  of  the  second 

portion  of  the  phalanges,  characteristic  of  gout. 


PLATE      LI  V 


Fig.  169 


Fig.  170 

Fig.  169. — Infectious  Arthritis.     Note  the  periarticular  swelling  and  irregular  joint  atrophy  with 

thinning  of  the  cartilage. 

Fig.  170. — Atrophic  Arthritis.     Note  the  general  bony  atrophic  destruction  of  several  joints  with 

corresponding  deformity. 


SECONDAKY  COMPLICATIONS  139 

duce  the  typical  lesions  and  symptoms  (lameness)  of 
arthritis.  The  organisms  recovered  from  the  arthritic  le- 
sions have  a  decided  tendency  to  again  localize  in  joints. 
In  some  cases  the  arthritis  was  the  only  lesion  found  at 
autopsy,  but  in  other  cases  it  was  associated  with  duodenal 
ulcer,  appendicitis,  cholecystitis,  myocarditis,  pericar- 
ditis, endocarditis,  nephritis,  colitis,  and  myositis.  ' '  The 
results  of  localization  obtained  in  connection  with  studies 
of  staphylococci,"  says  the  writer,  "are  singularly  sug- 
gestive of  Rosenow's  results  with  streptococci." 

The  causative  focus,  is,  according  to  Billings,  usually 
found  in  the  head,  but  may  be  found  anywhere  in  the 
body.  The  most  important  places  for  infectious  foci  are 
found  in  the  nose,  throat  (tonsils),  oral  cavity,  the  intes- 
tinal tract,  and  genito-urinary  system.  Septic  foci  may 
occur  in  different  parts  of  the  body  simultaneously,  as 
the  tonsils  and  the  teeth,  or  the  teeth  and  the  intestinal 
tract,  and  even  may  have  a  pathological  connection.  It 
is  rather  seldom  to  find  a  true  condition  where,  for  ex- 
ample, the  only  foci  are  found  in  the  mouth,  but  it  is 
evident  that  the  sufferers  from  chronic  arthritis  have 
almost  always  an  abundant  number  of  septic  lesions  in 
the  mouth,  which  without  question  may  have  been  respon- 
sible for  the  disease.  The  lesions  in  the  mouth  from 
which  haematogenous  infection  may  take  place  are 
principally  the  different  varieties  of  abscesses,  pyorrhoea 
pockets,  and  septic  bridgework.  The  streptococcus  is 
most  frequently  found  in  oral  abscesses,  as  has  already 
been  mentioned,  and  septic  processes  are  found  in  the 
mouth  of  a  very  large  percentage  of  people.  At  the 
Robert  B.  Brigham  Hospital  I  examined  eighty-seven 
patients,  from  which  number  seventy-two  or  eighty-nine 
per  cent,  had  abscesses  on  from  one  to  thirty-two  teeth. 
The  seventy-two  patients  had  three  hundred  and  forty 
abscesses  and  many  suffered  from  pyorrhoea  besides. 

Treatment :  The  treatment  consists  in  general  improve- 
ment of  the  metabolism  by  suitable  diet  and  open-air 
existence.  Then  comes  the  search  and  removal  of  all 
possible  foci  of  infection  and  absorption  to  eliminate 


140  ORAL   ABSCESSES 


radically  any  source  which  was  originally  responsible  for 
the  disease  and  may  cause  reinfection.  The  removal  of 
the  focus  does  not  necessarily  result  in  a  cure,  as  the 
secondary  joint  lesions  have  developed  to  a  certain  extent, 
but  it  frees  the  system  from  the  burden  of  continuously 
taking  care  of  those  conditions  and  gives  the  patient  a 
chance  for  an  effort  towards  recovery  from  other  diseased 
conditions.  Abscesses,  as  well  as  other  pus  conditions  in 
the  mouth,  should  therefore  be  radically  removed,  not 
only  because  the  system  absorbs  from  them  bacteria  and 
toxins,  but  also  because  many  have  sinuses  into  the  mouth 
through  which  pus  is  discharged,  which  deteriorate  the 
food  and  cause  gastric  and  intestinal  sepsis.  It  is  also 
important  to  restore  the  masticatory  apparatus  to  full 
efficiency.  The  teeth,  which  are  missing,  should  be  re- 
placed by  plates  or  by  removable  bridge  work,  because 
it  is  not  fair  to  expect  that  the  stomach  of  a  weakened 
patient  will  digest  food  which  has  not  been  properly  pre- 
pared in  the  mouth.  Local  treatment  of  the  diseased  joints 
and  consists  of  hydrotherapy  and  electric  baking  and 
massage. 

illustrative  Case  XXVIII.  (Infectious  arthritis.) 
(From  a  report  by  Dr.  Proctor.)  The 
patient,  a  young  girl,  aged  twenty-one, 
had  always  been  in  very  good  health.  As  a  child  she  had 
mumps  and  measles.  Has  not  had  scarlet  fever,  diph- 
theria, or  pneumonia.  Eleven  years  ago  the  patient  suf- 
fered considerably  from  nasal  catarrh,  with  sore  throat 
and  swelling  on  the  side  of  the  neck.  This  was  operated 
on  and  discharged  for  three  or  four  months.  Has  not 
been  subject  to  colds  or  sore  throats  since;  the  swelling 
on  the  neck  did  not  recur.  No  tuberculosis  or  arthritis 
or  carcinoma  in  the  family  history. 

On  Sunday,  August  16,  1914,  the  patient  had  an  ul- 
cerated tooth  (right  upper  central  incisor)  which  was 
giving  her  some  trouble.  The  following  morning  the 
pain  had  increased  and  the  face  was  swollen.  She  went 
to  the  dentist  to  have  it  attended  to.  He  lanced  an 
abscess  on  the  gum  and  gave  her  another  appointment 


SECONDARY  COMPLICATION'S  141 

for  the  following  Friday,  August  21.  During  the  interval 
between  these  visits  the  girl  suffered  very  great  pain  and 
could  not  sleep  nights.  The  dentist,  however,  filled  the 
tooth  with  a  gold  filling  and  told  the  girl  that  she  would 
have  to  expect  more  or  less  pain,  but  that  the  swelling 
would  soon  go  away.  When  she  went  home  from  this 
visit  her  face  was  so  swollen  that  her  mother  hardly  knew 
her.  After  four  or  five  days  the  face  started  to  become 
normal  and  at  the  same  time  the  left  ankle  began  to  get 
stiff,  and  shortly  afterward  the  right  ankle  became 
affected,  then  the  elbows  and  thumbs  became  stiff  and 
swollen.  The  joints  had  not  been  particularly  tender, 
but  the  condition  showed  a  tendency  to  steady  progres- 
sion until  the  patient  could  hardly  walk  on  account  of 
stiffness  and  pain.  The  first  physician  who  took  care  of 
her  thought  that  her  trouble  might  be  due  to  a  run-down 
condition,  and  as  she  grew  gradually  worse  under  his 
treatment  (she  saw  him  two  or  three  times  for  ten  weeks), 
she  was  advised  to  consult  another  physician,  who  diag- 
nosed her  case  as  infectious  arthritis,  with  the  abscessed 
tooth  as  the  causative  factor.  He  sent  her  to  the  Rhode 
Island  Hospital,  where  she  was  admitted  November  28, 
1914.  Physical  examination  showed  nose  and  throat 
negative,  heart  in  good  condition,  lungs  clear.  Abdomen 
no  masses,  no  tenderness.  On  December  22,  the  jaws 
started  to  get  stiff,  especially  the  right  side,  so  that  her 
eating  was  limited  to  well  chopped  or  soft  solid  foods.  On 
December  28,  the  terminal  joints  of  the  thumbs  were 
swollen  and  a  dull  grating  was  produced  on  manipulating 
the  joint.  In  March,  1915,  the  patient  went  home ;  at  this 
time  the  girl  was  perfectly  helpless  and  unable  to  feed 
herself;  she  had  to  stay  in  bed.  Dr.  Painter,  who  saw 
the  patient  in  December,  1915,  found  all  the  larger  joints 
involved  and  the  small  joints  of  the  hands.  She  was 
unable  to  sit  up  and  could  not  move  any  of  her  joints 
without  a  great  amount  of  pain.  Figure  171  shows  a 
radiograph  of  her  fingers ;  Figure  172  shows  the  condition 
of  the  devitalized  tooth.  Dr.  Painter  ordered  massage, 
regulated  the  diet ;  Dr.  Proctor  performed  apiectomy  on 


142  OKAL   ABSCESSES 


the  upper  central  incisor  on  December  24,  and  removed 
the  scar  tissue,  which  yielded  a  streptococcus  staphylo- 
coccus culture.  The  patient  improved  very  much  during 
the  following  three  months,  she  was  able  to  get  up  and 
go  about,  the  mouth  could  be  opened  wider.  In  April  she 
took  cold  and  had  a  relapse.  Dr.  Proctor  operated  on 
her  again  on  April  17,  having  better  access  to  the  mouth 
at  this  time.  The  root  of  the  right  lateral  incisor,  which 
was  found  devitalized,  was  amputated,  and  at  the  same 
time  he  removed  the  left  lower  third  molar  and  second 
bicuspid,  which  showed  abscessed  condition.  The  pa- 
tient improved  again  and  is  now  able  to  sit  up  in  a  chair. 

Case  XXIX.  Atrophic  arthritis.  Patient,  a  house- 
wife, of  sixty-nine  years,  was  admitted  to  the  Robert  B. 
Brigham  Hospital  on  July  3,  1914.  Had  had  measles, 
pertussis,  scarlet  fever  and  lung  fever,  when  a  child.  Her 
present  illness  started  two  years  previous.  Both  hands 
became  swollen.  This  swelling  was  white  and  painless; 
later  the  feet  became  affected,  and  the  eyes  were  inflamed. 
The  process  subsided  slowly  and  she  had  not  wholly  re- 
covered when  a  second  attack  was  suffered  one  year  before 
entering  the  hospital.  This  time  the  hands,  shoulders, 
neck  and  knees  were  affected  and  she  has  not  recovered 
from  this  attack.  Examination  showed  pupils  equal  and 
of  normal  reaction,  tonsils  not  enlarged,  throat  negative. 
No  glandular  enlargement  in  neck,  axillae  or  groin. 
Lungs  negative,  heart  action  irregular  and  systolic  mur- 
murs heard  at  apex  and  transmitted  to  axilla.  Spleen 
not  palpable,  kidneys  not  palpable,  abdomen  soft  and  full, 
no  masses  nor  tenderness. 

Diagnosis:  Infectious  arthritis  with  atrophic  changes. 
The  patient  received  house  diet  and  was  kept  in  bed  on 
account  of  the  cardiac  condition.  X-rays  of  joints  were 
taken.  X-rays  of  intestine  with  bismuth  meal  were  taken. 
The  knees,  elbows,  and  hands  showed  atrophic  changes. 
These  were  contracted  so  as  to  make  the  patient  appear 
as  bent  over. 

On  October  2  the  patient  was  ordered  to  the  hydro- 
therapy room  for  electric  treatment.     On  April  29,  1915,, 


PLATE     LV 


Fig.  171 


Fig.  171. — Badiographic  plates  of  one  hand  of  Case  No.  28,  showing  atrophic  destruction  of 
sev  ral  joints.     Note  the  periarticular  swelling. 


Fig.  173 


Pig.  172. — Radiograph  showing  the  bone  changes  about  the  incisor  which  origin- 
ally had  caused  the  infectious  arthritis  of  Case  No.  28,  the  radiograph  had  been 
taken  about  sixteen  months  after  the  patient  had  acute  symptoms. 

!FiG.  173. — Radiographic  plate  of  Case  No.  29,  showing  areas  of  disease  about  the 
roots  of  the  upper  first  molar  and  lower  first  and  second  molars. 


SECONDAKY  COMPLICATIONS  143 

X-rays  of  her  teeth  were  taken  and  showed  areas  of  bone 
absorption  on  the  upper  left  first  molar  and  the  upper 
right  second  bicuspid.  There  were  also  large  areas  on 
the  left  lower  first  and  second  molars,  and  the  right  lower 
second  molar.     (Figure  173.) 

I  extracted  the  teeth  and  curetted  the  abscess  cavities. 
After  two  weeks  the  patient  had  more  motion  in  the 
fingers  and  wrists,  although  there  were  still  areas  of 
swelling  and  tenderness.  Soon  after,  walking  for  a  few 
steps  was  successfully  attempted.  Improvement  con- 
tinued, and  after  three  months  she  was  able  to  walk  up 
and  down  stairs,  and  made  considerable  gain  in  the  use 
of  her  fingers  on  the  piano.  At  the  time  of  writing,  May, 
1916,  she  is  in  good  condition,  up  every  day,  eats  and 
sleeps  well,  walks  every  day,  and  has  considerable  motion 
in  her  fingers.    She  will  leave  the  hospital  shortly. 


CHAPTER  IX 


EXAMINATION    OF    THE    ORAL    CAVITY 

The  mode  of  examination  of  the  mouth  is  perhaps  today 
the  greatest  shortcoming  of  the  average  dentist.  The 
patient  who  trusts  his  family  dentist  entirely  takes  it 
for  granted  that  the  dentist's  examination  is  complete 
and  thorough,  and  believes  that  the  mouth  has  been 
restored  to  a  normal  and  healthy  condition  when  being 
dismissed.  The  radiologist's  examination  reveals  many 
unsuspected  abscesses  in  the  mouths  of  patients,  to  whose 
mouths  dentists  have  given  conscientious  if  mis- 
taken attention.  It  often  takes  a  good  deal  of  explana- 
tion to  righten  the  dentist's  position  in  such  cases  and  to 
sooth  the  patient's  anger  at  having  been  deceived.  While 
the  dentist,  of  course,  is  not  to  blame  for  conditions  which 
have  been  caused  and  have  developed  without  his  knowl- 
edge, the  situation  must  be  properly  explained.  The 
patient  will  be  quick  to  realize  that  the  dentist  had  only 
the  best  intentions  in  trying  to  save  every  tooth  as  an 
important  organ  of  mastication  and  that  he  surely  is  not 
to  blame  for  not  having  been  able  to  accomplish  the  im- 
possible in  correctly  treating  many  abnormally  devel- 
oped teeth  and  obstructed  root  canals,  and  for  not  know- 
ing that  such  dangerous  septic  conditions  can  exist  in 
his  patient's  mouth  without  giving  any  symptoms.  But 
today,  with  our  modern  means  of  examination,  where 
X-ray  machines  are  especially  adapted  for  our  purposes 
and  where  radiologists  are  to  be  found  in  almost  every 
street,  where  there  are  professional  men,  there  is  no 
excuse  for  a  dentist  to  neglect  to  ascertain  the  condition 
of  all  devitalized  teeth  in  his  patient's  mouth.  But  he 
who  only  fills  cavities,  constructs  bridges  and  makes 


PLATE      LVI  I 


♦  -w 


Fig.  174 


Fig.  175 


Fig.  176 


Fig.  177 


Fig.  178 


Fig.  179 


Fig.  174,  175,  176,  177,  178  and  179. — Radiographs  of  a  mouth  showing  a  large  amount 
of  crown  and  bridge  work  of  recent  date  and  a  great  many  abscess  areas. 


PLATE      LVI  II 


Fig.  180 


Fig.  181 


Fig.  182 


Fig.  183 


Fig.  184 


Fig.  185 


Figs.   180,   181,   182,   183,   184  and   185. — Radiographs   of   a  neglected   mouth   showing 
broken-down  teeth  and  abscess  areas. 


EXAMINATION  OF  OEAL  CAVITY  145 

plates  and  neglects  other  abnormal  or  diseased  conditions 
which  the  patient  does  not  particularly  complain  of, 
renders  poor  service  to  the  public.  The  dentist  is  the 
man  who  has  charge  of  the  mouth  and  he  has  a  great 
responsibility.  It  would  put  the  dental  profession  back 
to  the  age  of  the  mechanic  should  we  undertake  to  con- 
cern ourselves  only  with  mechanical  restoration  instead 
of  investigating  and  treating  every  disease  found  in  the 
region  of  our  domain.  What  would  we  think  of  an 
ophthalmologist  who  would  only  correct  abnormal  condi- 
tions of  the  lens  and  would  pay  no  attention  to  co-exist- 
ing iritis  or  other  inflammatory  diseases  of  the  eye  %  But 
we  find  exactly  parallel  cases  in  the  practice  of  many 
dentists. 

The  physician  often  has  occasion  to  in- 
method  OF  quire  into  the  condition  of  his  patient's 
P^fh.K.  A-n.sN*.  mouth,  especially  when  in  search  of  a 

EXAMINATION   #  i      •      A '  n         t 

for  the  iocus  or  ioci  oi  the  disease  concerning 

physician  which  the  patient  is  consulting  him.  Some 
medical  men  still  have  the  idea  that  the 
mouth  is  a  thing  apart  from  the  body  which  cannot  have 
any  influence  upon  the  general  health,  others  are  too  easily 
satisfied  with  the  patient's  statement  that  the  dentist  is 
visited  regularly  and  that  there  is  absolutely  nothing 
wrong  with  the  teeth,  but  the  thorough  physician  will  not 
be  satisfied  except  with  a  report  based  upon  a  careful 
examination  and  radiographic  diagnosis  made  by  a  den- 
tist or  radiologist  in  whose  judgment  he  can  trust. 

A  superficial  examination  of  the  mouth  by  the  physician 
should  include  the  following : 

1.  Examination  of  the  soft  tissues  of  the  mouth.  The 
tongue,  floor  of  the  mouth,  palate  and  gums  should  be  in- 
spected. Stomatitis  is  easily  detectable  and  in  pyorrhoea 
the  gums  are  inflamed  and  spongy,  and  pus  can  be 
squeezed  out  from  underneath  the  gum. 

2.  Examination  of  the  teeth.  Neglected  teeth  can  be 
recognized  at  a  glance ;  there  are  many  cavities  and  broken 
down  teeth  causing  abscesses  with  or  without  visible 
sinuses  on  the  gum. 


146  ORAL   ABSCESSES 


Overdentristried  teeth  are  of  a  most  deceiving  nature. 
Teeth  of  dark  appearance,  gold  and  porcelain  crowns  and 
bridges  always  come  under  suspicion,  because  these  are 
generally  signs  of  devitalized  teeth,  and  it  makes  no 
difference  whether  the  gums  are  inflamed  or  normal,  with 
no  sinus,  and  no  symptoms  of  inflammation  whatever. 
Radiographs  should  be  secured  of  such  teeth  as  this  is  the 
only  means  of  finding  out  their  condition. 

Impacted  and  unerupted  teeth  should  be  investigated 
by  the  X-ray.  If  some  teeth  are  missing  and  the  patient 
does  not  remember  that  they  were  extracted  it  is  possible 
that  they  are  in  malposition  and  cause  disturbance. 

3.  Enlarged  Lymph  Glands.  If  the  submental  or  sub- 
maxillary lymph  glands  are  enlarged,  it  is  almost  always 
a  sign  that  some  septic  process  is  going  on  in  the  mouth. 
Abscesses,  however,  may  occur  without  the  involvement 
of  the  glands. 

The  old  method  of  dental  examination  has 
METHOD  OF  already  been  criticized  in  the  first  part  of 
°v^h.*,A-n,Mu  this  chapter.  But  worse  than  the  method 
for™  he  of  examination  is  the  way  the  dentist 

dentist  keeps  his  records.    The  card  systems  and 

books  which  are  on  the  market  are  abso- 
lutely inefficient,  for  besides  a  place  for  bookkeeping  they 
provide  only  for  records  of  the  fillings  placed  in  the  teeth 
and  the  crowns  and  bridges  made  for  the  patient.  There 
is  no  arrangement  that  provides  for  the  marking  of  root 
canal  operations,  for  indicating  abscess  and  pyorrhoea 
conditions,  not  to  speak  of  other  diseases  which  may  be 
directly  or  indirectly  connected  with  the  conditions  found 
in  the  oral  cavity. 

The  dentist  should  inquire  into,  examine  and  record  the 
following  conditions : 

..„_.  1.    General  Health  of  the  Patient.    The 

examination  dentist  should  inquire  into  the  general 

condition  of  the  patient's  health  and  if  a 

history  of  systemic  disease  is  found  in  connection  with 

septic  processes  of  the  mouth,  the  patient  should  be  en- 


PLATE      LI  X 


Fig.  186 


Fig.  187 


Fig.  188 


Fig.  189 


Fig.  190 


Fig.  191 


Fig.  192 


Fig.  193 


Figs.  186  and  187, 


-Badiographs  revealing  deep  cavities  causing  obscure  pain, 
distal  side  of  the  first  molar. 


Both  on  the 


Fig.  188. — Badiograph  shows  a  large  amount  of  unsuspected  trouble. 
Figs.  189,  190,  191,  192  and  193. — Badiographs  showing  the  value  of  X-rays  before  undertaking 
root  canal  work.    In  Fig.  189  note  bent  apex  of  second  bicuspid  with  gold  crown.     In  Fig.  191, 
cuspid  with  root  bent  at  right  angle.     In  Fig.  192,  the  foramina  of  some  teeth  are  still  widely 
open.     In  Fig.  193  there  is  a  pulp  stone  in  the  pulp  chamber  of  the  first  molar. 


PLATE      LX 


Fig.  194 


mm  i 


Fig.  195 


Figs.  194  and  195.— Radiographs  of  a  mouth  which  was  examined  for  foci  and  report  chart 
indicating  the  granulomata  and  root  canal  fillings. 


EXAMINATION  OP  OKAJL  CAVITY  147 

couraged  to  consult  a  physician,  whose  cooperation  should 
be  secured  to  find  out  whether  there  is  any  connection 
between  the  two  conditions  and  what  further  treatment 
besides  the  treatment  of  the  oral  condition  could  be  of 
benefit  to  the  patient. 

2.  Diseases  of  the  Soft  Tissues.  The  tongue,  palate, 
floor  of  the  mouth  and  gums  should  be  examined  next. 
Abscesses,  ulcers,  cancers,  gummata,  palatal  perforations 
and  clefts,  benign  and  malignant  tumors,  cysts,  diseases 
of  the  salivary  glands  and  ducts,  inflammation  of  the 
throat,  stomatitis  and  pyorrhoea  may  be  noticed. 

3.  Diseases  of  the  Teeth.  Malocclusion  should  be  no- 
ticed in  children,  missing  teeth  and  lack  of  masticating 
efficiency  in  adults.  Cavities  may  be  in  plain  view  or  may 
only  be  discovered  after  most  careful  exploration.  If  the 
patient  complains  of  pain  the  teeth  should  be  tested  to 
find  out  diseased  conditions  of  the  pulp.  Applications 
of  ice  or  hot  instruments  to  the  various  teeth,  as  well  as 
the  galvanic  or  high  frequency  current  are  useful  aids 
to  diagnosis.  Acute  periodontitis  is  recognized  if  a  tooth 
is  tender  and  pain  is  caused  on  percussion,  acute  abscesses 
and  parulis  are  noticed  in  like  manner,  the  latter  causing 
noticeable  swelling  of  the  face  and  gum.  Sinuses  on  the 
gum  without  complaint  of  pain  and  tenderness  lead  to 
chronic  abscesses  caused  by  devitalized  teeth,  and  all  de- 
vitalized teeth  whether  they  cause  apparent  trouble  or 
not  should  be  recognized ;  these  are  usually  darker  in  ap- 
pearance, have  large  fillings  or  large  cavities,  porcelain 
crowns  or  gold  crowns  which  may  also  serve  as  abutment 
of  bridges.  Such  teeth  should  be  radiographed  to  find 
out  the  periapical  condition  and  the  quality  of  the  root 
canal  fillings.  Finally,  the  dentist  should  be  on  the  look- 
out for  impacted  and  unerupted  teeth,  which  usually 
sooner  or  later  become  a  source  of  serious  trouble.  In 
children  they  may  cause  malocclusion ;  in  adults,  various 
abnormal  and  diseased  conditions,  as  we  have  already 
seen. 


148  ORAL  ABSCESSES 


It  is  impossible  to  make  a  thorough  exam- 
graphic  ination  of  the  mouth  without  the  use  of 

examination  radiographs  in  patients  who  have  devi- 
talized teeth.  If  the  dentist  has  not 
an  X-ray  machine  of  his  own,  he  can  easily  secure 
radiographs  of  the  suspected  teeth  from  a  dental 
radiologist,  who  will  not  only  take  the  radiographs, 
but  will  also  give  valuable  advice  as  to  the  in- 
terpretation of  the  pictures.  It  is  indeed  a  great  ad- 
vantage to  be  able  to  consult  a  man  who  as  a  specialist 
sees  many  cases  and  therefore  has  a  much  greater  expe- 
rience in  radiographic  diagnosis  than  the  general  prac- 
titioner, and  the  fee  for  such  services  with  the  modern 
improvements  has  been  reduced  to  a  level  which  is  in  the 
realm  of  almost  every  person. 

Radiographs  are  principally  taken  to  find  obscure 
causes,  to  ascertain  physical  diagnosis,  to  diagnose  ob- 
scure conditions,  to  prognose  the  outcome  of  therapeutic 
measures,  the  possibilities  of  treatment  and  the  course  of 
surgical  technique. 

1.  Obscure  pain  may  be  diagnosed  by  means  of  radio- 
graphs and  found  to  come  from  decay  under  the  gingival 
margin  or  under  fillings,  from  impacted  and  unerupted 
teeth  or  cysts  and  acute  abscesses. 

2.  Diagnosis  of  Condition  of  Devitalised  Teeth.  The 
use  of  radiographs  to  find  out  the  conditions  of  pulpless 
teeth  has  revolutionized  the  attitude  towards  devitaliza- 
tion of  teeth.  It  made  us  realize  the  difficulty  and  value  of 
good  root  canal  fillings  and  the  consequences  of  neglect 
and  inability  to  perform  perfect  root  canal  work.  Radio- 
graphs show  whether  the  root  fillings  reach  the  apex  or 
whether  the  canal  is  only  filled  part  way.  Broken  root- 
canal  instruments  are  detected  as  well  as  perforations  at 
the  side.  The  apex  may  show  a  ragged  appearance,  which 
is  a  sign  of  necrosis  of  the  root ;  or  it  may  appear  enlarged 
and  bulging  on  account  of  exostosis  of  the  cementum. 
There  may  be  an  area  of  lessened  density  around  the  apex 
showing  loss  of  bone ;  this  indicates  an  abscessed  condition 
or  a  granuloma.    Similar  areas  occur  sometimes  on  the 


PLATE      LX1 


f    i       I  /i 


(     ffl    ( 


)  h 


(1 


(W 


Fig.  196. — Eeeord  chart  as  used  by  Dr.  Potter  and  reproduced  with  his  permission. 


% 


EXAMINATION  OF  ORAL  CAVITY  149 

side  of  a  root  or  between  the  roots  of  multirooted  teeth. 
There  may  also  be  absorption  of  bone  at  the  cervical  part 
of  the  alveolar  process  surrounding  the  bone,  indicating 
pus  pocket. 

3.  Prognosis  Before  Boot  Canal  Treatment.  It  is  of 
great  importance  to  make  sure  of  the  probable  outcome 
before  involving  the  patient  in  lengthy  and  expensive 
root  canal  treatment.  The  radiograph  may  show  normal 
canals,  open  apical  foramina,  accessory  foramina,  bent 
and  curved  roots,  inacessible  canals  on  account  of  sec- 
ondary dentine,  pulp  stones  or  broken  root-canal  instru- 
ments. Abscess  formation  and  necrosis  of  the  apex  may 
be  discovered  which  would  indicate  the  necessity  of  sur- 
gical interference  and  generally  gives  an  idea  whether  a 
tooth  can  be  saved  or  not,  whether  the  root  canals  can  be 
treated  with  medicines,  and  the  canal  filled  to  the  apex, 
whether  apiectomy  is  practical  and  indicated  to  save  the 
tooth  or  whether  the  tooth  has  to  be  extracted. 

All  these  findings  should  be  recorded  on  a 
charts  CASE  chart.    Professor  William  H.  Potter,  who 

realized  the  shortcomings  of  the  ordinary 
dentist's  examination  charts,  took  much  pains  in  arrang- 
ing a  practical  chart  on  which  all  dental  conditions  can 
be  marked  down.  Figure  196  shows  an  examination  re- 
corded on  his  chart.  The  plates  also  have  historic 
interest:  they  are  copies  of  originals  from  Carabelli*. 
The  back  of  the  chart  is  arranged  for  book-keeping. 

Similar  but  simpler  charts  have  been  made  up  by  the 
author  for  reports  of  radiographic  examination.  This  is 
sent  with  the  radiographs  and  gives  the  dentist  a  better 
idea  and  clearer  picture  of  the  condition  of  the  whole 
mouth,  which  can  be  verified  by  the  radiographs.  In  this 
chart  the  radiologist  can  interpret  the  radiographic 
findings  so  that  they  are  plainly  visible.  Such  a  chart 
is  seen  in  Figure  195. 

*  Carabelli  :  Die  Anatomie  des  Mundes. 


CHAPTER  X 


TREATMENT  OF  ORAL  ABSCESSES 

The  treatment  of  oral  abscesses  varies  with  the  ana- 
tomical location  and  with  the  condition  of  the  inflamma- 
tion. The  treatments  of  the  various  conditions  will  be 
discussed  under  the  following  headings : 

1.  Treatment  of  acute  and  subacute  conditions. 

2.  Treatment  of  chronic  conditions. 

3.  Treatment  of  abscesses  due  to  diseases  of  the  gums. 

4.  Treatment  of  abscesses  from  impacted  and  un- 
erupted  teeth. 

5.  Treatment  of  abscesses  of  the  tongue. 

6.  Treatment  of  abscesses  of  the  salivary  glands  and 
ducts. 

7.  Treatment  of  systemic  conditions. 

1.    Treatment  of  Acute  and  Subacute  Conditions. 

In  treating  acute  conditions  we  should  carefully  differ- 
entiate between  acute  and  subacute  inflammation.  In 
acute  inflammation,  especially  in  the  beginning  stage 
where  there  is  little  destruction  of  tissue,  the  tissue  reacts 
easily  to  treatment  and  complete  regeneration  is  possible. 
In  subacute  cases,  however,  a  chronic  condition  has  pre- 
viously existed,  the  root  may  be  necrosed,  and  the  reaction 
of  the  tissue  is  therefore  not  sufficient  to  produce  com- 
plete recovery  when  the  acute  symptoms  subside.  The 
inflammation  passes  back  into  the  quiescent  and  persis- 
tent chronic  stage.  It  is  therefore  important  to  diagnose 
the  cause  correctly,  and  distinguish  between  the  acute 
condition  which  occurred  as  a  primary  infection  of  the 
periapical  tissue,  from  an  infected  pulp,  and  the  subacute 


TREATMENT  151 


condition,  which  can  be  recognized  by  the  history  or  by  a 
radiograph  showing  that  the  root  canal  had  been  treated 
or  filled  previously.  In  the  subacute  cases,  extraction  is 
indicated  unless  the  conditions  are  favorable  for  apiec- 
tomy,  but  before  this  operation  can  be  performed,  the 
same  treatment  is  indicated  as  for  the  acute  conditions 
until  the  symptoms  quiet  down,  when  the  tooth  can  be 
filled  and  surgically  treated. 

Acute  periodontitis  sometimes  can  be 
the  cause       topped   and   extensive   alveolar   abscess 

prevented  by  prompt  removal  of  the 
cause.  In  the  later  stages  of  acute  abscess  it  is  of  equal 
importance  to  eliminate  the  causative  factor,  which  is  a 
suppurating  pulp.  When  opening  into  the  tooth  use  a 
good  sized  round  burr,  holding  the  tooth  firmly  by  making 
a  plaster  cast  for  each  side,  so  as  to  decrease  the  jarring 
and  to  prevent  further  irritation.  If  there  is  much  pain, 
conductive  or  general  anaesthesia  is  indicated.  Remove 
the  largest  part  of  the  pulp  in  a  gentle  manner  so  as  not 
to  press  infected  material  through  the  apical  foramen. 
If  the  radiograph  indicates  that  abscess  formation 
has  already  begun,  it  may  be  advisable  to  enlarge 
the  root  canal  and  apical  foramen  so  as  to  get  reasonably 
free  access  to  the  abscess.  All  this  is  done  under  aseptic 
precautions.  A  mild  antiseptic  dressing  is  placed  into 
the  tooth,  such  as : 


Buckley's  Modified  phenol: 

Mentholis    gr.  xx 

Thymolis  gr.     xl 

Phenolis F3  iij  MX 

Black  recommends : 

01.  cassiae  1  part 

Phenolis   2  parts 

01.  gaultheriae    3  parts 

Mx  oils  and  add  melted  crystals  of  phenol. 

Close  the  opening  of  the  tooth  with  cotton  dipped  in  liquid 
petroleum ;  this  prevents  saliva  from  entering,  but  allows 


152  ORAL   ABSCESSES 


gases  which  may  be  formed  in  the  canals  to  escape. 
Change  the  dressing  daily  until  the  tooth  feels  more  com- 
fortable, when  the  dressing  can  be  sealed  into  the  tooth 
with  base  plate  gutta  percha.  After  the  root  canals  have 
been  cleaned  and  sterilized,  they  should  be  filled,  so  as  to 
seal  the  apical  foramina  hermetically.  Only  by  scru- 
pulous asepsis,  careful  treatment  and  technique  can  re- 
currence or  chronic  continuation  be  prevented.  This  tech- 
nique will  be  described  in  the  chapter  on  prevention. 

To  avoid  further  irritation  the  affected 
d  Leased™  E  el°ngated  tooth  should  be  put  at  rest. 
tooth  This  is  best  done  by  building  up  the  occlu- 

sial  surface  of  all  the  teeth  of  one  jaw 
with  copper  cement  except  in  the  position  of  the  tender 
tooth. 

Counter-irritants  are  beneficial  to  help 
of  counter^  a^sorD  the  abscess.  Apply  on  both  sides 
irritants        °^  ^ne  gum>  over  the  affected  root,  tincture 

of  iodine,  tincture  of  iodine  and  aconite, 
or  chloroform;  these  are  the  most  common  counter-irri- 
tants. They  should  be  applied  to  the  dried  mucous  mem- 
brane. Suction  cups  containing  counter-irritants  are 
applied  on  the  gum  opposite  the  apex  of  the  root. 

In  some  cases  of  acute  abscess,  we  can 
latomy  £a^n  sufficie^  drainage  through  the  root 

canal  to  affect  a  cure.  This  is  true  for 
upper  teeth  if  treatment  is  started  before  the  destructive 
process  has  progressed  too  far.  In  lower  teeth  this  is  al- 
most impossible,  because  the  process  is  not  aided  by  gravi- 
tation. The  abscess  in  the  mandible  is  also  of  much  more 
severe  nature,  more  pain  is  produced,  and  a  longer  time  is 
required,  because  of  anatomical  conditions,  till  the  pus 
burrows  an  opening  through  the  bone  to  the  surface. 
Great  relief  and  good  drainage  can  be  secured  by  an  arti- 
ficial opening  through  the  alveolar  process.  Under  con- 
ductive or  general  anaesthesia  we  incise  the  gum,  retract 
it  to  both  sides,  and  with  a  large  round  burr  drill  through 
the  process  to  the  apex  of  the  tooth.  The  opening  should 
be  made  at  the  lowest  level.    The  root  canal  can  be  opened 


TREATMENT  153 


at  a  future  sitting,  though  I  prefer  to  do  it  at  once.  If  the 
apical  foramen  can  be  penetrated,  irrigation  through  the 
tooth  is  indicated.  Normal  salt  or  mild  antiseptic  solu- 
tion should  be  used.  Put  a  mild  antiseptic  dressing  into 
the  tooth,  as  already  described,  and  a  wick  into  the  arti- 
ficial sinus  to  prevent  premature  closing  of  the  wound. 
I  prefer  to  use  a  cigarette  wick  made  of  rubber  tissue; 
this  does  not  disintegrate.  The  abscess  should  be  irri- 
gated daily  until  no  more  pus  is  discharged,  when  the 
root  canal  can  be  filled.  The  wound  should  heal  from  the 
bottom ;  this  is  accomplished  by  shortening  the  wick.  If 
suppuration  persists  we  must  ascertain  the  cause.  Usu- 
ally this  comes  from  necrosis  of  the  tooth  and  can  only  be 
cured  by  amputation  of  the  diseased  part. 

In  cases  presenting  a  subperiosteal  or  subgingival  paru- 
lis,  an  early  incision  will  quickly  relieve  the  pain.  The 
pus,  which  has  already  penetrated  the  outer  plate  of  the 
bone  and  collected  in  large  quantity  under  the  periosteum 
or  gum,  cannot  be  expected  to  drain  back  through  the 
bone  and  root  canal  of  the  tooth.  Therefore  we  should  at 
once,  under  conductive  or  general  anaesthesia,  secure  a 
large  incision  at  as  low  a  level  as  possible.  In  case  of 
subperiosteal  parulis,  which  is  particularly  liable  to  cause 
extensive  necrosis,  especially  if  it  is  of  long  duration,  this 
incision  should  be  very  extensive  so  as  to  give  free  drain- 
age. Some  authors  recommend  leaving  the  tooth  alone 
until  the  acute  symptoms  have  subsided,  but  I  prefer  to 
remove  the  cause  at  once.  If  conductive  or  general  an- 
aesthesia is  used,  this  may  be  effected  when  the  abscess  is 
incised.  An  opening  should  be  drilled  into  the  tooth  and 
the  bulk  of  the  diseased  pulp  is  removed.  The  incision 
is  made  on  the  gum  as  described.  The  pus  should  be  taken 
up  with  a  sponge,  especially  under  general  anaesthesia. 
The  point  of  a  piston  syringe  or  fountain  syringe  is  in- 
serted into  the  root  canal  and  the  whole  area  is  washed 
out  thoroughly  with  normal  salt  or  mild  antiseptic  solu- 
tion. Under  general  anaesthesia  this  solution  should  be 
taken  up  by  sponges  and  not  left  to  run  into  the  mouth. 


154  ORAL   ABSCESSES 


Under  conductive  anaesthesia  the  management  is  much 
simpler  and  the  whole  treatment  can  be  done  more  success- 
fully. The  incision  should  be  kept  open  by  means  of  a 
wick  made  of  rubber  tissue,  and  the  washing  should  be 
repeated  until  the  discharge  of  pus  stops.  The  opening 
in  the  tooth  can  be  closed  temporarily  after  an  antiseptic 
dressing  has  been  placed  into  the  root  canal.  After  the 
root  canal  has  been  cleaned  and  sterilized  it  can  be  filled, 
and  if  this  is  correctly  done,  the  abscess  will  not  recur  or 
continue  as  a  chronic  lesion  unless  the  periodontal  mem- 
brane has  been  destroyed  at  the  apex  of  the  root  or  become 
necrosed  during  the  period  of  suppuration.  In  such 
cases  we  have  to  resort  to  apiectomy  or  extraction. 
extraction  ^e  most  radical,  but  usually  also  the 
quickest  relief  is  extraction  of  the  offend- 
ing tooth.  If  the  patient's  resistance  is  low  so  that  a 
speedy  healing  by  the  application  of  any  one  of  the  above 
methods  cannot  be  expected,  or,  if  high  fever  or  com- 
plications set  in,  it  is  almost  always  advisable  to  resort 
to  more  radical  means.  If  extraction  is  decided  upon,  it 
should  be  undertaken  at  once,  because  nothing  is  gained 
by  waiting.  It  is  an  erroneous  idea  that  a  tooth  should 
not  be  extracted  during  the  acute  stage.  Nothing  gives 
a  more  spontaneous  result  than  elimination  of  the  cause 
and  establishment  of  drainage  through  the  alveolar 
socket.  The  extraction  should  be  performed  under 
general  or  local  conductive  anaesthesia.  Spray  the  mouth 
thoroughly  and  paint  the  tooth  and  surrounding  gum 
with  iodine  to  prevent  secondary  infection.  The  extrac- 
tion should  be  followed  by  curettage,  after  which  the 
wound  is  freely  irrigated,  treated  with  iodine,  and  lightly 
packed  with  gauze.  Antiseptics  and  anodines  can  be  ap- 
plied on  this  dressing;  iodoform,  orthoform,  or  the  fol- 
lowing preparation  is  of  benefit : 

Eur  of  orm  paste : 

Orthoform 40 

Europhen    60 

Add  liquid  petroleum  to  make  a  paste. 


TREATMENT  155 


The  wound  should  be  irrigated  daily  and  granulation 
should  be  allowed  to  fill  the  cavity  from  the  bottom.  An 
antiseptic  mouth  wash  should  be  used  freely  and  often 
and  held  in  the  mouth  for  five  to  ten  minutes  at  a  time. 
If  the  socket  does  not  fill  in  with  granulation  tissue 
speedily  it  is  advisable  to  procure  a  slight  hemorrhage 
with  a  sterilized  instrument.  The  socket  is  then  filled 
with  a  blood  clot  which  organizes  in  a  very  short  time. 
In  cases  where  the  disease  has  progressed  to  the  stage  of 
parulis,  an  incision  should  be  made  on  the  gum  in  addi- 
tion to  the  extraction  and  communication  established  from 
the  gum  to  the  socket.  Curette  the  diseased  process  and 
irrigate  profusely.  The  socket  is  treated  with  tincture 
of  iodine  placed  into  the  wound  of  the  gum  to  drain  the 
abscess  and  permit  the  socket  to  fill  in  with  a  blood  clot. 
The  dressing  is  changed  every  day  until  suppuration  is 
stopped,  when  the  wound  is  left  to  heal. 

For  Palliative  Effect.  A  hot  foot-bath 
treatment  an(^  cathartic  should  be  ordered.  Pre- 
scribe the  foot-bath  as  follows :  A  tub  is 
partly  filled  with  warm  water  and  the  feet  immersed. 
Hotter  water  is  added  to  raise  the  temperature  of  the  bath 
to  the  greatest  degree  that  can  be  tolerated.  Powdered 
mustard  may  be  dissolved  in  warm  water  and  added  to  the 
foot-bath.  (Do  not  dissolve  the  powder  directly  in  the 
hot  water;  it  would  defeat  the  action  necessary  to  pro- 
duce the  irritant  volatile  oil.)  Keep  the  feet  in  the  water 
five  to  ten  minutes.  The  effect  is  dilation  of  the  blood 
vessels  in  the  lower  extremities,  reducing  the  blood  pres- 
sure in  the  head.  After  the  foot-bath  the  feet  should  be 
thoroughly  dried  and  the  patient  should  go  to  bed,  which 
has  been  warmed  beforehand.  It  is  essential  not  to  step 
on  a  cold  floor  with  the  bare  feet,  or  to  chill  the  feet  in 
any  way,  because  this  would  contract  the  vessels  again 
and  spoil  the  effect. 

For  a  cathartic  prescribe  castor  oil  in  gelatine  capsules. 
Six  2y2  gram  capsules  should  be  taken  before  retiring. 


156  ORAL  ABSCESSES 


Other  laxatives  are: 

Tab.  Caseara  Sagrada  a.a.  0.3  chocolate  coated. 
Sig.    One  to  two  tablets  before  retiring. 

or, 

Aloini  gr.  1/5 

Strychnia     gr.  1/120 

Ext.  Belladonna  Fol gr.  0/8 

S.     Take  one  to  two  pills  before  retiring. 
An  alternative  may  also  be  given  in  certain  cases : 

Potassii  iodidi    6.0  g.  —  3  jss. 

Syrupi  sarsaparillae  comp.  90.0 — f3  iij. 

Sig.    Take  a  teaspoonful  in  water  every  2  hours 
till  3  doses  are  taken,  then  a  teaspoonful  after  meals. 

For  Belief  of  Pain.  Phenacetin  and  aspirin  have 
been  found  by  the  author  the  most  effective  antipyretic 
for  pain  in  the  trigeminal  region.  Give  gr.  V  of  each  and 
repeat  after  one  hour  if  necessary.  Trigeminin  gr.  V  or 
pyramidon  gr.  II  s.s.  sometimes  prove  of  value.  To  tide 
the  patient  over  a  very  severe  attack  or  to  give  a  night's 
rest  a  hypnotic  may  be  used.  Tab.  Bromural  (Knoll  & 
Co.)  a.a.  0.3  (gr.  V)  two  to  three  tablets  before  retiring 
should  be  given.    In  extreme  cases : 

Morphiae  sulph 0.015     gr.  14 

Kalii  Bromid 2.0         gr.  xxx 

Aquae 30.0         3i 

Sig.    One  half  to  be  taken  at  once ;  balance  in  three 
hours,  if  needed. 

For  prompt  relief  give  %  or  %  Er-  morphine  hypo- 
dermically. 

Diet.  Order  a  light,  easily  digestible  diet  which  is 
strengthening  at  the  same  time. 


TREATMENT  157 


treatment      "^  a  smus  ^°  ^ne  ^ace  exists  we  always 
of  sinus  have  to  resort  to  extraction  of  the  respon- 

TO  face  s^e  tooth.     The  discharging  of  an  ab- 

scess in  the  face  is  often  invited  by 
poultices  or  hot  applications  to  the  face.  This  should  be 
avoided;  poultices  if  used  should  be  applied  to  the  gum 
and  cold  applications  only  to  the  face.  If  a  sinus  exists 
it  should  be  curetted  and  washed.  After  extraction  of 
the  tooth  and  curetting  of  the  diseased  area  the  sinus  will 
close  up  speedily;  unfortunately,  however,  not  without 
leaving  a  permanent  mark.  This  scar  can  be  improved 
somewhat  by  excision  of  the  fibrous  connection  which 
fixes  the  skin  to  the  bone  and  closing  of  the  wound  by  a 
plastic  operation. 

2.    Treatment  of  Chronic  Condition. 

Chronic  abscesses  in  all  stages  are  of  very  persistent 
character  and  the  fact  that  they  cause  none  of  the  car- 
dinal symptoms  makes  it  extremely  hard  to  ascertain  in 
a  general  way  whether  the  lesion  is  yielding  to  treatment 
or  not.  Even  the  radiograph  for  this  special  purpose 
is  not  always  a  safe  means  of  finding  out,  because  lighter 
and  darker  shadows,  smaller  and  larger  areas  can  be 
obtained  by  variation  in  the  exposure,  the  quality  of  the 
ray,  the  depth  of  the  development  and  the  angle  at  which 
the  exposure  is  made.  Generally  we  may  say  that  as  long 
as  there  is  any  area  of  lessened  density  at  all  and  as  long 
as  the  root  end  is  necrosed  we  cannot  claim  to  have  cured 
the  abscess. 

Antiseptic  treatment  of  chronic  abscesses  has  for  a 
long  time  been  the  treatment  per  se.  A  large  number  of 
drugs  have  been  and  still  are  in  use.  They  are  either 
forced  through  the  apical  foramen  but  more  frequently 
are  only  applied  into  the  root  canal  of  the  tooth  by 
means  of  cotton  dressings,  and  it  is  left  to  their  power  of 
evaporation  to  penetrate  into  the  diseased  periapical 
tissue  and  cure  the  abscess.  Ionic  medication  has  been 
recommended  to  carry  the  antiseptic  into  the  diseased 


158  ORAL   ABSCESSES 


tissue.  Careful  experiments  with  these  methods  and  a 
variety  of  drugs  proved  to  my  satisfaction  that  there  is 
today  no  antiseptic  known  that  has  sufficient  penetrating 
and  sterilizing  power  to  destroy  bacterial  life  completely 
in  the  periapical  granulomata.  I  have  treated  blind  ab- 
scesses of  medium  size  from  the  root  canal  with  all  known 
methods  and  found  such  treatment  extremely  uncertain, 
if  not  entirely  insufficient.  Grieves,*  whom  I  consider 
one  of  the  most  thorough  investigators,  makes  the  follow- 
ing statement  about  treatment  of  pericemental  condi- 
tions: "There  is  to  my  knowledge  no  medicament  nor 
method,  germicidal,  oxydizing  or  electrolytic,  that  will 
revivify  the  pericemental  apex.  If  it  be  vital,  the  tooth 
is  healthy ;  if  it  be  diseased,  the  tooth  is  next  to  doomed. 
This  is  the  point  in  treatment  where  materia  medica  stops 
and  good  surgery  begins. ' ' 

This  is  exactly  my  opinion,  based  upon  histopatho- 
logical  study,  as  shown  in  Chapter  VI,  and  investigations 
especially  undertaken  to  study  the  value  of  the  different 
popular  methods  of  medication. 

Original  Investigation  of  the  Efficiency  of  Medication 
for  the  Treatment  of  Granulomata. 

Five  teeth  in  different  patients  have  been  used  for  ex- 
periments. All  cases  showed  an  area  of  about  pea 
size  and  were  of  long  standing.  I  first  used  antiseptic 
dressings  until  there  was  no  more  odor.  Teeth  1  and  2 
received  no  further  treatment.  Teeth  3  and  4  received 
zinc  ions,  milliampere  for  ten  minutes  on  two  different 
days,  the  fifth  tooth  received  iodine  ions  %  to  1  milliam- 
pere for  fifteen  minutes  on  two  days.  Tooth  1  was  ex- 
tracted ;  on  tooth  2  apiectomy  was  performed.  Cultures 
were  made  both  from  root  apex  and  abscess  and  showed 
bacterial  growth.  Tooth  3  was  extracted.  No  growth 
from  the  root  apex,  slight  bacterial  growth  from  the  ab- 
scess.   Apiectomy  was  undertaken  on  tooth  4  and  bac- 

*  Grieves,  C.  J. :  Dental  Periapical  Infection  as  the  Cause  of  Systemic  Disease. 
Dental  Cosmos,  January,  1914. 


TREATMENT  159 


terial  growth  was  received  from  both  abscess  and  root. 
Tooth  5  was  also  a  case  of  root  amputation;  the  abscess 
yielded  a  culture  of  staphylococcus  albus  and  a  few  very 
small  chains  of  streptococci. 

Another  case  showed  the  inefficiency  of  ionic  medica- 
tion in  the  treatment  of  the  chronic  abscess ;  Mr.  R.  suf- 
fered with  arthritis  and  especially  complained  of  toxemia 
and  decreased  mental  capacity.  He  had  to  stop  smoking 
as  the  system  was  not  able  to  take  care  of  the  nicotine. 
From  radiographic  examination  I  concluded  that  there 
were  chronic  abscesses  on  left  upper  first  and  second  bi- 
cuspids and  proliferating  periodontitis  on  the  left  upper 
cuspid.  The  root  canals  were  carefully  cleaned  and 
treated  with  medicines,  zinc  ions  were  used  twice  and 
iodine  ions  once,  then  I  filled  the  canals.  Much  care  was 
taken  in  condensing  the  root  canal  fillings  which  resulted 
in  forcing  the  root  canal  cones  through  the  foramina. 
During  the  treatment  the  patient  received  great  relief 
and  finally  got  rid  of  the  systemic  conditions,  his  head 
was  clear  in  the  morning,  and  he  was  especially  pleased 
that  he  could  again  smoke  "like  a  chimney."  After  five 
or  six  months  he  returned,  however,  saying  that  his  old 
symptoms  were  returning.  I  delayed  treatment  for  four 
or  five  weeks  longer,  when  he  was  almost  as  bad  as  before. 
Radiographs  showed  about  the  same  amount  of  decreased 
density  about  the  two  bicuspid  roots.  Apiectomy  was  per- 
formed and  cultures  procured.  These  yielded  a  bacterial 
growth  and  the  symptoms  disappeared  almost  entirely 
several  days  after  the  operation. 

From  these  observations  I  conclude  that  in  cases  where 
we  do  not  deal  with  a  purely  local  condition,  but  where 
the  patient's  health  is  involved,  more  radical  treatment 
than  medication  is  recommendable. 

A  chronic  alveolar  abscess  or  granuloma  looked  at  from 
the  viewpoint  of  the  bone  instead  of  the  tooth  is,  as 
already  mentioned,  an  osteomyelitic  condition;  the  dis- 
ease occurs  in  the  bone  and  at  the  expense  of  the  bone, 
and  the  only  reason  why  the  disease  does  not  spread  more 


160  ORAL   ABSCESSES 


easily  is  due  to  the  abundant  blood  supply  of  the  jaws  and 
the  protecting  reaction  of  the  tissues  which  form  a  fibrous 
layer  at  the  periphery  of  the  lesion  enclosing  the  seat 
of  suppuration.  In  cases  where  there  is  necrosis  of  the 
root,  and  necrosis  occurs  in  most  all  roots  surrounded  for 
a  long  time  by  chronic  inflammation,  it  is  impossible  to 
cure  the  condition  without  getting  rid  of  the  diseased 
part  by  surgical  means.  In  cases  where  the  disease  has 
not  progressed  beyond  the  apical  part,  the  usual  condi- 
tion, we  can  separate  the  necrosed  part  of  the  tooth  sur- 
gically and  curette  the  bone,  which  will  induce  prompt 
healing  of  the  condition.  This  operation  permits  us  to 
extirpate  the  abscess  radically,  remove  the  necrosed  root 
end  surgically,  and  still  save  the  tooth. 
removal  of  J^so  ™  c^ron^c  disease  it  is  imperative  to 
the  CAUSE       remove  the  primary  cause.    The  principal 

cause  of  proliferating  periodontitis  and 
granulomata  is  the  condition  of  septic  and  imperfectly 
filled  root  canals.  Our  aim  therefore  ought  to  be  to 
thoroughly  cleanse  the  root  canal  and  remove  all  infected 
tissue.  Root  canal  treatment  and  root  canal  filling  are 
operations  which  require  considerable  skill  and  patience. 
The  technique  will  be  described  in  the  chapter  on  pre- 
vention. 

Antiseptics  applied  into  the  root  canal 
treatment  have,  as  already  discussed,  been  used  for 
with  anti-  a  iong  time  to  render  the  tooth  aseptic. 
placed  ■*■  ^°  no^  think  that  they  ever  were  meant 

into  the  to  be  used  for  treatment  of  chronic  ab- 

ROOT  canal     scesses,  and  their  insufficiency  for  this 

purpose  has  already  been  enlarged  upon, 
but  it  may  be  wise  to  say  also  that  formaldehyde, 
either  alone  or  combined  with  other  drugs,  has  never 
been  meant  to  be  the  cure  of  all  pulp  and  periapical  dis- 
eases. Dr.  G-.  Y.  Black  has  described  at  length  its  irrita- 
ting action  and  its  power  of  destroying  periodontal  mem- 
brane, and  Buckley  himself  has  stated  that  formaldehyde 
acts  only  on  the  surface  and  has  no  penetrating  power. 


TREATMENT  161 


IONIC 
MEDICATION 


Ionic  medication  is  advisable  in  all  those 
cases  of  short  standing  where  the  prolif- 
eration of  the  periodontal  membrane  is  of 
small  extent  and  where  the  apex  has  not  been  affected  by 
necrosis  nor  the  periodontal  membrane  destroyed.  The 
effect  of  ionic  medication  is  to  distribute  into  the  sur- 
rounding tissues  the  antiseptic  placed  in  the  root  canal. 
The  dentinal  tubules,  as  well  as  accessory  foramina,  are 
sterilized  by  this  method,  which  prevents  later  reinfec- 
tion. The  therapeutic  action  depends  on  the  drug  used ; 
zinc,  copper,  silver,  and  iodine  are  most  commonly  em- 
ployed. 

Zinc  Ion.  A  zinc  electrode  is  used  with  a  three  per 
cent,  solution  of  zinc  chloride  applied  on  a  few  fibres 
of  cotton.  Place  the  zinc  broach  into  the  root  canal. 
The  positive  pole  is  used  in  the  tooth,  the  negative  pole 
is  held  in  the  hand,  or  applied  to  the  cheek,  and  one-half 
to  three  milliamperes  are  applied  for  from  five  to  fifteen 
minutes.  The  action  of  zinc  chloride  is  tissue  destruc- 
tive. It  is  used  by  some  men  to  destroy  the  granuloma, 
which  is  then  thought  to  be  resorbed. 

Copper  Ion.  A  two  per  cent,  solution  of  copper  sul- 
phate is  used  with  a  copper  anode  on  the  positive  pole. 
One  milliampere  seems  to  give  a  good  dissociation  of  ions. 
Its  action  is  similar  to  zinc  chlorid. 

Iodine  Ion.  Tincture  of  iodine  is  used  and  applied 
on  the  negative  pole,  preferably  on  an  iridium  platinum 
electrode.  Use  one  half  to  three  milliamperes  for  five  to 
fifteen  minutes.  To  be  safe  the  treatment  should  be 
repeated. 

Action  of  Antiseptic  Ions.  The  effect  of  ionic  medica- 
tion is  to  distribute  the  antiseptic  deeper  into  the  tissues. 
Its  action  is  destructive  to  bacteria.  The  zinc  ion  seems 
to  be  the  most  effective,  but  like  the  copper  ion,  it  seems 
to  have  a  decidedly  irritating  and  tissue  destructive,  if 
not  escharotic  or  caustic  effect.  Symptoms  of  swelling 
and  pain  have  been  observed  after  the  treatment  in  several 
cases  by  the  author,  and  for  this  reason  the  iodine  ions  are 
more  commendable.     It  has  only  a  bactericidal  action 


162  ORAL   ABSCESSES 


and  does  not  destroy  the  tissue,  and  is  well  known  as  the 
great  antiseptic.  I  have  used  an  aqueous  solution  of 
iodine  lately.  It  has  all  the  iodine  properties  minus  the 
irritating  action,  and  also  penetrates  more  profusely  in 
moist  tissue.  Ionic  medication  with  iodine  is  of  great 
importance  for  root  canal  sterilization  and  is  to  be  highly 
recommended  for  routine  practice  to  sterilize  in  a  proper 
way  the  dentinal  tubules  and  accessory  foramina  of  a 
tooth,  as  will  be  described  in  the  chapter  on  prevention. 
apiectomy  Apiectomy  is  an  operation  by  which  we 
can  positively  eliminate  a  chronic  abscess 
without  sacrificing  the  tooth.  It  is  the  only  sure  method 
of  treatment  if  the  apex  of  the  root  is  diseased,  if  the 
apical  periodontal  membrane  is  destroyed,  if  the  root 
canal  cannot  be  treated  and  filled  to  the  very  end,  if  the 
side  of  the  root  has  been  perforated  near  the  apex  by  a 
root-canal  instrument,  or  if  an  instrument  has  been 
broken  off  in  the  end  of  the  root.  It  can  also  be  per- 
formed on  teeth  that  carry  crowns  or  bridges  if  the  root 
canal  is  accessible  and  properly  treated  and  filled  previous 
to  the  operation.  Not  all  teeth,  however,  are  favorable 
cases.  The  operation  is  impossible  on  third  and  almost 
always  on  second  molars.  The  first  molars  are  frequently 
accessible,  and  all  the  remaining  teeth  can  easily  be 
operated  upon. 

The  operation  consists  in  opening  through  the  side  of 
the  alveolar  process,  amputation  and  removal  of  the  dis- 
eased root  apex  and  thorough  curettage  of  the  diseased 
bone.     It  is  a  strictly  aseptic,  surgical  operation. 

Radiographic  examination:  A  careful  examination  of 
the  condition  of  the  occlusion  and  a  study  of  the  length 
and  shape  of  the  root  by  means  of  a  good  radiograph  is 
imperative.  The  condition  of  the  root  canal  should  be 
investigated ;  from  the  radiograph  we  can  judge  how  well 
we  shall  be  able  to  fill  it.  Observe  also  the  position  of  the 
neighboring  teeth  and  how  much  alveolar  process  to  hold 
the  tooth  there  will  be  left  after  the  operation.  A  tooth 
with  pyorrhoea  or  with  an  apical  periodontitis  extending 
almost  to  the  alveolar  border  is  not  a  favorable  case,  be- 


PLATE       LX I  I 


Fig.  197 


Fig.  198 


Fig.  199 


Fig.  200 


Figs.  197,  198,  199  and  200.— Apiectomy,  on  the  left  upper  cuspid.     Fig.  197  shows  incision, 

Fig.  198  gum  and  periosteum  retracted,  Fig.  199,  cutting  of  a  window  into  the  alveolar  process 

to  expose  the  root  end,  Fig.  200,  the  root  end  and  granuloma  exposed. 


PLATE      LXI V 


Fig.  205 


Fig.  206 


/m 


Fig.  207 


Fig.  208 


me  none  cavity      Figs    206  and  207  show  the  first  horse-hair  suture      Fio-   208 
shows  the  completed   operation. 


TREATMENT  163 


cause  after  the  operation  there  would  not  be  enough 
periodontal  membrane  or  bone  left  to  give  firm  attach- 
ment to  the  tooth ;  neither  should  a  tooth  be  operated  on 
if  the  tooth  next  to  it  has  also  a  chronic  abscess  which 
will  either  directly  or  indirectly  reinfect  the  healing 
tissue. 

Treatment  of  the  Root  Canal.  Apiectomy  is  only  suc- 
cessful if  the  root  canal  has  been  sterilized  and  properly 
filled  previous  to  the  operation.  It  is  not  sufficient 
simply  to  amputate  the  root  where  the  old  filling  ends ;  but 
the  root  canal  and  dentinal  tubules  have  to  be  sterilized, 
or  there  will  be  reinfection  from  the  tubules  exposed 
where  the  root  is  cut.  If  it  is  not  worth  while  to  remove 
a  crown  and  treat  the  root  canal,  the  tooth  should  be  ex- 
tracted or  there  will  be  recurrence  (with  or  without 
symptoms)  and  the  patient  is  as  badly  off  as  before.  It 
is  not  justifiable  to  leave  a  crown  on  a  tooth  because  it  is 
a  masterpiece  of  art,  if  the  foundation  upon  which  it  is 
built  ruins  the  patient's  health.  The  root  canal  should 
be  rendered  aseptic  by  application  of  antiseptics  or  by 
ionic  medication.  It  should  be  filled  with  the  rosin-chlo- 
roform-gutta-percha method,  which  has  the  advantage 
of  making  the  point  adhere  firmly  to  the  root  canal.  Dr. 
William  H.  Potter,  Professor  of  Operative  Dentistry, 
Harvard  University  Dental  School,  inserts  root  canal 
fillings  with  pure  lead  points.  That  pure  lead  is  accep- 
table to  the  tissue  has  been  proven  by  the  encapsulation 
of  bullets  in  almost  any  part  of  the  body.  It  has  the 
advantage  of  being  burnishable  from  the  abscess  cavity, 
of  not  disintegrating,  and  of  safely  staying  in  place  dur- 
ing root-canal  reaming  for  fitting  of  a  post  and  crown.  I 
use  the  following  method  for  lead  fillings :  Dehydrate  the 
root  canal  with  acetone  and  hot  air,  dry  with  electric  root 
canal  dryer  until  the  patient  feels  the  heat.  Fill  chloro- 
form and  resin  (dram  I  to  gr.  IY)  with  a  sub-Q  syringe 
into  the  canal  and  insert  a  gutta-percha  point  or  cone, 
pumping  it  forty  times  up  and  down.  Remove  the  re- 
mains of  the  point  and  insert  a  lead  cone,  previously  steri- 
lized by  boiling  it  or  immersing  it  for  five  minutes  into 


ORAL   ABSCESSES 


phenol  and  five  minutes  into  alcohol.  Condense  the  filling 
as  well  as  possible  with  root  filling  condensers  so  that  it 
adapts  itself  to  the  walls.  Any  filling  or  crowning  of  the 
tooth  is  performed  before  the  operation  so  as  not  to  dis- 
turb the  healing  process. 

Preparing  the  Patient  for  the  Operation.  If  local  an- 
aesthesia is  used,  it  sometimes  is  necessary  to  use  pre- 
operative treatment,  especially  in  nervous,  apprehensive, 
and  hysteric  patients.  Bromural-Knoll  (alphabrom- 
isovaleryl  urea)  is  an  excellent  sedative;  one  tablet  is 
given  to  children,  two  to  adults  (in  water  thirty  minutes 
before  the  operation),  or  ^4  gram  of  morphia  hypoder- 
mically  one  hour  before  the  operation. 

Preparing  the  Field  of  Operation.  The  mouth  should 
be  sprayed  out  with  an  antiseptic  solution,  and  the  mu- 
cous membrane  should  be  cleaned  with  a  cotton  roll  in  the 
area  where  we  intend  to  operate. 

Anaesthesia.  Local  anaesthesia,  applied  by  the  im- 
proved technique*  with  novocain  suprarenin  is  best 
adapted  for  this  operation.  The  amount  of  suprarenin 
should  not  be  too  large,  because  too  much  local  anaemia 
is  undesirable,  making  it  almost  impossible  to  procure 
enough  hemorrhage  at  the  end  of  the  operation  to  fill  the 
bone  cavity  with  blood. 

Radiograph.  A  new  intraoral  radiograph  can  be  taken 
at  this  stage,  while  we  wait  for  the  anaesthesia  to  take 
effect.  This  is  essential  to  ascertain  the  extent  of  the 
root  canal  filling. 

Preparation  for  the  Operation.  The  operation  should 
be  performed  on  the  principles  of  aseptic  surgery.  The 
instruments  have  been  selected  beforehand,  have  been 
boiled  and  put  on  a  sterile  table,  and  are  covered  with  a 
sterile  towel  until  they  are  used.  A  sterile  table  is  pre- 
pared to  deposit  the  instruments  for  use,  the  patient  is 
covered  with  a  sterile  sheet,  and  in  order  to  exclude  the 
hair,  the  head  is  covered  with  a  sterile  towel  except  over 

*  See  Thoma  :  Textbook  on  Oral  Anaesthesia. 


PLATE      LXV 


Fig.  209 


Fig.  210 


Fig.  211 


Figs.  209,   210   and  211. — Radiographs    of    three    cases 

which  are  not  favorable  for  apieetomy  because  the  bone 

and  periodontal  membrane  has  been  diseased  from  the 

apex  to  the  neck  of  the  tooth. 


PLATE      LXV 


Fig.  212 


Fig.  216 


Fig.  213 


Fig.  218 


Fig.  217 


Fig.  219 


Fig.  214 


Fig.  215 


Fig.  220 


Fig.  212  and  Fig.  216. — The  patient  has  five  devital:zed  teeth  w'th  granuloma.     Ore 

tooth    had    to    be    extracted    on    each    side.        The    treatment,    filling,    hr'd^ework    nM 

apiectomy  which  was  finally  performed  is  seen  in  Figs.  213,  214  and  215,  for  one  side, 

Figs.  217,  218,  219  and  220  for  the  other  side. 


TREATMENT  165 


the  eyes,  nose,  and  mouth.  It  goes  without  saying  that 
the  operator  wears  sterile  gowns  and  gloves. 

Operation.  The  saliva  ejector  is  put  in  place  by  the 
assistant  and  the  lip  is  retracted  with  a  lip  retractor.  One 
sterile  syringe  is  placed  on  either  side  of  the  part  that  is 
to  be  operated  so  as  to  prevent  saliva  entering  the  field 
of  operation.  The  mucous  membrane  is  dried  with 
sterile  gauze  and  painted  with  3y2  per  cent,  iodine  or 
aqueous  solution  of  iodine. 

Incision.  With  a  flap  knife  make  a  "U  "-shaped  in- 
cision, as  shown  in  the  picture.  Lift  the  periosteum  and 
gum  from  the  bone  with  the  sharp  periosteal  elevator. 
Insert  a  suitable  gum  retractor  and  use  sterile  gauze  to 
remove  the  blood. 

Amputation  of  the  Root.  The  alveolar  process  is  now 
visible  if  it  has  not  been  destroyed  by  the  granulation. 
A  good-sized  opening  is  cut  with  the  chisel  and  mallet,  or 
by  aid  of  the  burr  to  get  a  clear  view  of  the  apex  of  the 
root.  Resect  the  apex  with  a  fissure  burr  at  a  point  fur- 
ther down  than  the  extent  of  the  root-canal  filling  and  as 
far  toward  the  cervical  part  as  is  necessary  to  remove  all 
parts  which  are  necrosed.  Remove  the  resected  apex 
with  a  suitable  elevator. 

Curetting  of  the  Abscess  Cavity.  The  most  important 
part  is  still  ahead.  This  is  the  removal  of  the  granulation 
tissue  and  curetting  of  the  alveolar  process  with  a  round 
burr,  until  all  granulation  and  osteomyelitic  bone  is  re- 
moved and  healthy  bone  is  visible  on  all  sides. 

Treatment  of  the  Wound.  Smooth  carefully  with  the 
burr  all  sharp  points  and  margins  of  the  alveolar  process. 
Do  not  shape  the  distal  part  of  the  tooth  like  the  end  of 
a  root,  as  it  is  sometimes  advised,  because  this  still  de- 
creases the  amount  of  attachment  with  the  bone.  Also, 
I  prefer  to  have  one  round,  clean  cavity  without  anything 
projecting  into  it.  Wash  with  normal  salt  solution,  re- 
move all  the  debris,  sponge,  and  sterilize  the  whole  cavity 
with  3%  per  cent,  iodine  or  aqueous  solution  of  iodine. 
Remove  the  excess  with  sterile  sponges  and  stimulate 
bleeding  with  a  suitable  instrument.     When  the  cavity  is 


166  OEAL   ABSCESSES 


filled  up  with  a  blood  clot,  draw  the  flap  over  the  opening 
and  sew  it  carefully  with  three  horse  hair  stitches. 

Healing.  If  proper  aseptic  care  has  been  taken,  a 
good  union  of  the  gum  is  obtained  in  a  short  time.  The 
stitches  are  removed  after  three  days  and  if  horsehair  has 
been  used,  this  causes  little  or  no  discomfort.  In  my 
mind,  the  sewing  in  the  mouth  is  of  greatest  importance ; 
it  prevents  reinfection  from  saliva  and  the  fluids  of  the 
mouth.  The  healing  of  the  bone  cavity  occurs  by  organi- 
zation of  the  blood  clot,  and  bone  is  later  formed  from  this 
tissue.  In  some  of  the  radiographs  it  can  be  seen  how 
the  trabeculae  of  bone  grow  into  the  cavity.  Ultimately 
the  tooth  becomes  ankylosed  at  the  end  to  the  newly- 
formed  bone.  The  patient  should  be  told  that  the  face 
may  swell  up  the  following  day  as  a  result  of  the  mechan- 
ical injury,  for  which  dry  heat  can  be  applied.  After 
three  or  four  days  the  face  is  normal  again.  After-pain 
is  very  seldom  noticed. 

Failures  and  Dangers. 

The  anatomical  relations  of  the  jaw  should  be  kept  in 
mind:  in  the  upper  jaw  the  proximity  of  the  antrum,  in 
the  lower  bicuspid  region  the  mental  foramen,  and  if 
operating  on  the  lower  molars  the  relation  to  the  man- 
dibular canal.  If  the  operation  is  performed  with  per- 
fect aseptic  precautions  there  is  very  little  danger. 
Failures,  however,  may  occur  either  because  the  granu- 
lation tissue  has  not  been  entirely  removed,  because  a 
neighboring  tooth  may  be  involved,  because  the  tooth  has 
not  been  sterilized,  or  because  the  cement  of  the  root  may 
be  discolored  and  necrotic  almost  to  the  cervical  margin. 
The  last  two  reasons  are  the  most  important  ones  and 
always  cause  reinfection,  which  can  only  be  cured  by 
extraction.  I  want  to  make  it  very  plain  that  this  opera- 
tion is  not  a  short  cut  to  save  the  removal  of  a  crown,  and 
proper  treatment  of  the  root  canal,  and  it  is  only  success- 
ful if  that  work  has  been  previously  accomplished 
satisfactorily. 


PLATE      LXVI  I 


Fig.  221 


Fig.  222 


Fig.  223 


Fig.  224 


Fig.  225 


Fig.  226 


Fig.   227 


Fig.  228 


Fig.  229 


Fig.  230 


Fig.  231 


Fig.  232 


Fig.  233 


Fig.  234 


Fig.  235 


S?ectomv'on2»'  l^ra^'nw'  *l?  ^  ?2-7 '~  RadioSraph?  showing  the  different  steps  of  root  canal  treatment  and 
apiectomy  on  a  lateral  incisor,  which  had  imperfect  root  filling  and  apical  granuloma.  Fig.  226,  taken  directly  after 
Vtcs    9o«    o9q    ,qn        a   oo-,        t>    j,-  operation.      Fig.    227   four  months  later. 

taken  two  month*  »ft»r  tiT  «  f-  °g*?lphiS  sho?'inS  th.e  treatment  for  apiectomy  on  another  lateral  incisor.  Fig.  231  is 
taken  two  months  after  the  operation,  the  bone  is  starting  to  fill  in.     The  excised  granuloma  of  this  case  is  seen  in  Figs! 

Figs.  232.  233,  234  and  235.— Radiographs  showing  the  process  of' apiectomy  on  two  teeth,  the  lateral  incisor  and  cuspid. 


PLATE      LXVIII 


Fig.  237 


Fig.  239 


Fig.  241 


Fig.  236 


uU:       I 


Fig.  238 


Fig.  240 


Fig.  242 


Figs.  236,  237  and  238. — Eadiographs  showing  apiectomy  on  a  first  bicuspid.     Fig.  23 
immediately  after  the  operation.     Fig.  238  shows  the  process  of  healing,  six  months  later. 

Figs.   239,   240,   241   and   242. — Apiectomy   on   a   cuspid.     Fig.   241    directly   after   the 
operation.     Fig.  242,  nine  months  after  the  operation. 


TREATMENT  167 


If  apiectomy  is  ruled  out  as  the  advisable 
anTTACT,ON  treatment  for  one  reason  or  another,  we 
CURETTAGE  still  have  the  most  radical  treatment 
left;  this  is  extraction  of  the  tooth  and 
curettage  of  the  bone.  This  treatment  radically  and 
positively  removes  not  only  the  lesion,  but  also  its  cause. 
I  lay  great  stress  on  the  removal  of  the  chronic  abscess 
with  the  curette  or  surgical  burr.  After  washing  the 
wound,  the  alveolar  socket  should  be  inspected  and  curet- 
ting is  repeated  if  all  has  not  been  removed.  Very  fre- 
quently we  find  a  definite  abscess  in  the  radiograph,  but 
after  the  tooth  has  been  extracted,  there  is  no  abscess 
attached  to  the  tooth,  and  if  we  inspect  the  socket  there 
is  only  bone  to  be  seen.  This  may  be  due  to  the  fact  that 
the  lamella  of  the  alveolar  socket  has  not  been  destroyed 
by  the  disease  and  that  it  has  to  be  broken  through  at  the 
bottom  if  we  want  to  reach  the  granulation.  After  the 
curetting  has  been  completed  the  wound  is  again  in- 
spected, and  if  all  the  bone  looks  healthy,  I  sterilize  the 
wound  with  3%%  iodine  or  aqueous  solution  of  iodine, 
and  then  allow  the  socket  to  fill  with  blood.  The  blood 
clot  will  organize  and  form  new  tissue. 

After  the  bleeding  is  stopped,  the  patient  is  instructed 
to  use  a  mouth  wash,  and  is  asked  to  return  for  inspection 
of  the  healing  wound  and  for  treatment. 

In  severe  systemic  disorders,  if  the  patient  has  a  low 
resistance,  or  in  any  weak  person,  it  is  necessary  to  use 
proper  judgment  in  determining  the  number  of  teeth  that 
are  to  be  extracted  at  one  time.  I  have  in  many  cases 
noticed  an  exacerbation  after  surgical  treatment,  and 
Hartzel  reports  that  he  has  noted  an  exacerbation  of 
joint  inflammation  in  all  arthritic  patients  following 
surgical  treatment  of  pyorrhoea  or  curettage  of  abscesses. 
A  sudden  extensive  removal  of  a  large  number  of  lesions 
may  cause  positive  harm,  especially  in  weakened  patients 
who  have  suffered  a  long  time,  and  where  the  protective 
cells  have  been  worn  out  from  long-continued  chronic 
focal  infection.  It  is  therefore  not  advisable  to  extract 
a  large  number  of  teeth  at  one  sitting,  or  to  remove  all 


168  ORAL   ABSCESSES 


the  teeth,  and  the  tonsils  the  same  day,  while  the  succes- 
sive removal  of  the  foci  will  benefit  the  patient ;  the  action 
of  this  process  will  be  described  later  under  surgical  auto- 
inoculation. 

FYTiRPATinM  ^e  ex^irPa^on  °f  teeth  with  chisel  or 
OF  TEETH  burr,  or  both,  is  an  operation  performed 

as  the  last  resort,  if  extraction  by  forceps 
and  elevator  have  failed.  But  often  it  is  indicated  as  a 
typical  primary  operation,  if  the  case  is  diagnosed  as  a 
difficult  one  by  means  of  radiographic  examination. 

Indication.  Extirpation  of  roots  and  teeth  is  specially 
indicated  in  cases  of  extensive  exostosis  of  the  root  apices, 
or  in  cases  of  broken  down  roots,  partly  or  entirely 
covered  by  the  gum,  and  especially  if  the  distal  teeth  have 
moved  forward  so  that  the  root  is  too  large  for  the  space. 

Anaesthesia.  Local  anaesthesia  or  local  and  general 
anaesthesia  combined  can  be  used.  The  decreased  bleed- 
ing obtained  by  local  injections  is  desirable,  especially  in 
the  back  of  the  mouth. 

Preparation.  Sensitive  and  apprehensive  patients 
should  receive  a  sedative,  such  as  Bromural-Knoll,  two 
tablets  to  adults,  in  water,  thirty  minutes  before  the 
operation,  if  local  anaesthesia  is  used.  One  hour  before 
the  operation  %  gram  of  morphia  with  or  without  atropin, 
as  required,  hypodermically,  is  used  before  a  general  an- 
aesthetic. 

Preparing  the  Field  of  Operation.  The  mucous  mem- 
brane should  be  dried  and  the  area  to  be  operated  on  is 
painted  with  tincture  of  iodine  or  aqueous  solution  of 
iodine.     The  saliva  is  taken  care  of  by  the  saliva  ejector. 

Incision.  Several  types  of  incisions  are  used  accord- 
ing to  location  and  condition.  It  should  be  large  enough 
to  prevent  laceration  of  the  soft  tissue  and  give  a  clear 
view  of  the  field  of  operation. 

Operation.  After  the  retractors  are  inserted  remove 
the  outer  part  of  the  alveolar  process,  so  as  to  expose  the 
entire  root  or  roots ;  in  molars  the  roots  should  next  be 
separated,  and  this  is  best  done  with  a  fissure  burr.  The 
root  or  roots  are  then  luxated  with  an  elevator,  after 
which  the  sockets  are  curetted  and  the  edges  of  the  bone 


PLATE     LXIX 


Fig.  243 


Fig.  244 


Fig.  245 


Fig.  246 


Fig.  251 


Fig.  252 


Fig.  253 


Figs.  243,  244,  245  and  246. — Apieetomy  on  a  cuspid  which  is  an  abutment  for  a  bridge.     The 

pulp  had  died.     No  root  filling.     Fig.  244  shows  root  filling.     Fig.  245,  immediately  after  the 

operation.     Fig.  246,  after  eight  months. 

Figs.  247  and  248. — Apieetomy  on  a  lateral  incisor. 

Figs.  249  and  250. — Apieetomy  on  a  central  incisor. 
Figs.   251,   252   and   253. — Apieetomy   on  two   teeth,   central   and  lateral   incisors.     Fig.   251, 
directly  after  the  operation.     Fig.  252  shows  the  healing  process  after  two  months.     Fig.  253 

shows  the  bone  completely  filled  in  after  ten  months. 


PLATE      LXX 


Fig.  254 


Fig.  255 


Fig.  256 


Fig.  257 


Fig.  258 


Fig.  259 


Fig.  260 


Figs.  254  and  255. — Apiectomy  on  a  lower  incisor. 

Fig.  256. — Apiectomy  on  two  lower  incisors. 

Figs.  257  and  258. — Apiectomy  on  a  lower  incisor  with  broken  root  instrument  in 
apical  part  of  the  root  canal. 

Figs.  259  and  260. — Apiectomy  on  a  lower  bicuspid,  the  molar  was  extracted  at 

the  same  sitting. 


TREATMENT  169 


smoothed  with  the  surgical  burr.  It  is  important  to  re- 
move all  pieces  of  process  which  are  fractured  or  pro- 
jecting so  as  not  to  prolong  or  hinder  the  healing  process. 
Care  of  Wound.  The  gum  should  be  placed  back  and 
sutured  to  its  original  position.  The  wound  is  washed 
with  normal  salt  solution  until  all  debris  is  removed,  and 
then  treated  with  3%  per  cent,  tincture  of  iodine  or 
aqueous  solution  of  iodine.  In  cases  of  chronic  abscesses 
the  wound  can  be  filled  in  with  a  blood  clot  if  the  curettage 
has  been  performed  properly,  but  in  cases  of  active  sup- 
puration, I  prefer  to  pack  the  socket  with  iodoform 
gauze,  saturated  with  orthoform  or  novocain  powder  to 
prevent  pain.  A  mixture  of  orthoform  powder,  novocain, 
and  campho-phenique  is  also  most  excellent  for  this  pur- 
pose. The  wound  should  be  irrigated  and  dressed  until 
filled  in  with  granulations. 

3.    Treatment  of  Abscesses  Due  to  Diseases  of  the  Gum. 

Abscesses  Due  to  Injury  of  the  Gum.  The  abscesses 
which  start  at  the  gingival  part  of  the  gum  respond  easily 
to  treatment  as  soon  as  the  cause  is  removed.  Foreign 
substances,  irritating  fillings  or  crowns  should  be  taken 
care  of,  the  abscesses  should  be  incised  and  washed  out. 
Iodine  is  most  effective  as  a  therapeutic  agent. 

Abscesses  Due  to  Pus  Pockets.  Abscesses  caused  by 
the  closing  of  a  pyorrhoea  pocket  should  be  incised  to 
evacuate  the  pus.  The  tooth  is  scaled  until  all  debris 
attached  to  it  are  removed.  After  washing  with  normal 
salt  solution,  treatment  with  iodine  is  found  beneficial. 
Ionic  treatment  is  also  highly  recommended.  Most  of 
these  cases  are  due  to  pyorrhoea  and  the  treatment  of 
pyorrhoea  will  not  be  considered  in  this  book. 

4.    Treatment  of  Abscesses  Due  to  Difficult  Eruption, 
Impaction  and  Unerupted  Teeth. 

Radiographic  examination  is  imperative  in  all  cases 
of  impacted  and  unerupted  teeth,  not  only  to  make  sure 
of  the  diagnosis,  but  also  to  find  out  the  position  of  the 
tooth  and  to  determine  the  course  of  treatment.  Intraoral 
films  often  give  good  results,  but  generally  I  prefer  a 


170  ORAL   ABSCESSES 


plate.  With  many  patients  it  is  hard  to  use  an  intraoral 
film  on  account  of  trismus  or  a  sensitive  throat,  and  often 
we  get  only  the  crown  of  the  tooth  in  the  picture,  and 
while  it  is  possible  to  determine  from  this  how  the  crown 
is  interlocked,  it  leaves  us  in  doubt  about  the  formation  of 
the  roots.  From  this  radiograph  we  should  be  able  to 
ascertain  the  number  of  roots,  their  form,  as  well  as  the 
location  of  the  tooth  in  regard  to  the  ramus  and  mandi- 
bular canal. 

extirpation  -^  imPacted  teeth  which  give  rise  to 
OF  II mp acted  pathological  conditions,  such  as  abscess 
and  pockets  or  pain  caused  by  pressure,  neural 

UN  erupted  anc[  mental  irritation,  should  be  promptly 
teeth  extirpated.     This  involves  a  difficult  and 

serious  operation  in  which  sometimes  the  skill  of  the  oral 
surgeon  is  taxed  to  its  highest  degree.  The  technique  of 
the  operation  I  shall  not  mention  here,  but  a  few  words 
about  pre-anaesthetic  medication,  anaesthesia  and  after- 
treatment  may  be  of  use.  The  physician  has  not  yet  gen- 
erally appreciated  the  difficulty  of  this  operation,  and  the 
dentist  has  not  until  lately  recognized  the  value  of  proper 
preparation  and  the  after-treatment  necessary  for  the 
extirpation  of  impacted  teeth,  as  well  as  other  oral  sur- 
gical operations.  If  the  operation  is  performed  under 
local  conductive  anaesthesia,  which  is  the  anaesthesia  of 
choice,  it  should  be  preceded  by  administration  of  an 
hypnotic  or  narcotic,  such  as  Bromural-Knoll,  two  tab- 
lets in  water  half  an  hour  before  the  operation,  or  in  more 
serious  cases,  morphine  gr.  1/6  to  gr.  *4,  or  morphine,  gr. 
y±,  and  atropine,  gr.  1/150.  This  stupifies  the  patient  so 
as  to  take  away  the  terror  of  the  operation,  and  appre- 
hension of  the  instrumentation.  It  also  relieves  the 
after-pain  associated  with  such  an  operation.  Many  pa- 
tients, however,  prefer  a  general  anaesthetic,  which  also 
should  be  preceded  by  the  usual  preanaesthetic  medica- 
tion. General  and  local  anaesthesia  may  be  combined 
to  great  advantage  to  overcome  the  physical  as  well  as 
psychic  shock.  All  depends  of  course  a  good  deal  upon 
the  attitude  of  the  patient  and  the  difficulty  of  the  case. 
A  good  many  impacted  or  unerupted  teeth  can  be  extir- 


PLATE      LXXI 


Fig.  261 


Fig.  264 


Fig.  267 


Fig.  262 


Fig.  265 


Fig.  268 


Fig.  263 


Fig.  266 


Fig.  269 


Figs.  261,  262  and  263. — Series  of  radiographs  showing  healing  of  the  bone  cavity.    Fig. 
262,  immediately   after   operation.     Fig.   263,   after   about   one  year. 

Figs.  264,  265  and  266. — The  condition  before  the  operation  is  seen  in  Fig.  264.     Fig.  265 

shows  the  healing  after  a  few  weeks.     Fig.  266  shows  complete  filling  in  of  the  bone 

cavity  after  about  fourteen  months. 

Figs.  267,  268,  269. — Radiographs  showing  the  healing  process  after  apiectomy.     Fig. 
268  shows  bridges  of  bone  growing  into  the  cavity.     Fig.  269  the  condition  after  about 

one  year. 


PLATE      LXXII 


Fig.  270. — A  selection  of  curettes. 


TREATMENT  171 


pated  without  great  effort,  and  in  a  comparatively  short 
time,  while  others  call  into  action  the  greatest  operating 
skill.  The  easy  cases  can  easily  be  performed  in  the 
office,  while  hard  cases,  in  apprehensive  and  neurasthenic 
patients,  should  be  done  at  the  hospital,  where  the  patient 
can  receive  proper  preanaesthetic  treatment  and  have 
proper  care  and  medication  for  a  few  days.  After  the 
operation  great  pain  is  usually  experienced,  especially 
after  the  removal  of  lower  impacted  wisdom  teeth,  which 
frequently  extend  into  the  mandibular  canal.  To  com- 
bat the  pain,  give  morphia  gr.  1/6  to  gr.  ^4  hypoder- 
mically,  later,  if  the  pain  is  less  severe,  the  following 
powders  have  been  found  excellent  by  the  author : 

Phenacetin  0.7     gr.  xii 

Sodium  bicarbonate 1.03  gr.  xx 

Codeine  sulphate 0.06  gr.  i 

Caffeine  citrate 0.24  gr.  iv 

Mx  et  devide  chartulas  in  powders  No2  iv. 

Sig.     One  powder  every  three  hours  until  relieved. 

If  there  is  only  a  small  amount  of  pain  prescribe : 

Phenacetin — 

Aspirin aa.         2.0  gr.  xxx 

Mx  et  devide  chartulas  in  powders  No2  vi. 

Sig.     Take  one  powder  every  hour  until  relieved. 

5.    Treatment  of  Abscesses  of  the  Tongue. 

The  treatment  of  abscesses  of  the  tongue  depends  very 
much  upon  the  duration  of  the  lesion  and  the  differen- 
tiation of  the  simple,  the  phlegmonous,  and  tubercular 
type. 

In  simple  abscesses  of  the  tongue  with 

tuber-      onty  moderate  infiltration,  a  small  deep 

"      incision  is  all  that  is  necessary.    The  ab- 

scess  cavity  is  drained  and  kept  open  by 

an  iodoform  wicking,  which  is  changed 

until  suppuration  has  stopped  and  the  wound  healed.    In 

the  severe  type  of  phlegmonous  abscess  of  the  tongue,  it 


172  ORAL,  ABSCESSES 


is  important  to  incise  as  early  as  possible.  General  an- 
aesthesia is  usually  necessary  to  open  the  mouth,  which 
is  locked  by  muscular  trismus,  so  that  the  tongue  can  be 
properly  palpitated  and  the  cause  ascertained.  The  an- 
aesthetic should  be  given  by  a  method  which  makes 
aspiration  of  pus  and  blood  impossible.  If  an  abscess 
is  the  cause  of  the  disease,  this  should  be  widely  opened 
first,  and  if  due  to  a  tooth  or  teeth,  these  should  be  ex- 
tracted without  hesitation.  The  tongue  then  is  drawn 
forwards  and  pressed  towards  the  healthy  side.  Its 
muscle  is  deeply  incised  with  a  crescent-shaped  knife  by  a 
horizontal  cut,  which  should  start  as  far  back  as  possible 
and  reach  way  forward  near  the  point  through  the  thick, 
ungainly,  deformed  substance  of  the  tongue.  There  may 
be  not  much  discharge  of  pus  from  the  tongue,  except  a 
small  amount  of  badly  smelling  liquid,  which  almost  al- 
ways flows  from  the  wound.  This  is,  however,  enough 
to  lessen  the  dangerous  increase  of  the  swelling  and  give 
relief  to  the  angina,  feared  more  than  anything  else  by 
the  patient.  The  mouth  gag  should  stay  in  the  mouth 
until  the  patient  has  awakened,  when  the  danger  of  aspir- 
ing blood  and  pus  is  passed. 

Small  tubercular  lesions  should  be 
OFSMALL  thoroughly  excised  and  the  wound  sutured 

tubercular  immediately.  Lactic  acid  is  used  by 
LESSONS  Brophy  to  sterilize  the  wound,  and  the  use 

of  the  X-rays  is  recommended  as  post- 
operative treatment. 

This  operation  is  recommended  by  Krause 
E)^siON  OF  arLC^  Seymann  for  tuberculosis,  gumma, 
the  TONGUE    Denign   tumors    and   selected   malignant 

tumors  which  involve  only  the  tip  of 
the  tongue.  Under  anaesthesia  the  tongue  is  drawn 
forward  and  a  thread  of  heavy  silk  is  then  drawn 
through  each  side  as  far  back  as  possible.  These 
hold  the  tongue  in  position .  A  V-shaped  incision  is 
now  made  in  the  healthy  tissue,  a  good  distance 
away  from  the  diseased  part.  In  order  to  lose 
the  least  amount  of  blood,  the  incision  is  only  made  two- 


PLATE     LXXII 


Fig.  271 


Fig.  272 

Figs.  271  and  272.— Excision  of  tip  of  tongue  as 
described  in  text. 


TREATMENT  173 


thirds  deep,  the  anterior  part  is  held  with  a  tongue  for- 
ceps and  drawn  forward,  and  silk  sutures  are  inserted  at 
once  to  draw  the  two  sides  together.  After  several 
stitches  are  inserted,  the  incision  is  continued  towards 
the  floor  of  the  mouth  on  one  side.  When  the  lingual 
artery  is  divided,  the  vessel  should  be  seized  with  a  haem- 
ostatic forceps  and  ligated.  The  same  thing  is  done  on 
the  other  side.  The  sutures  are  continued  while  the  two 
sides  are  drawn  together.  A  new  tip  is  thus  formed  by 
the  dorsal  part  of  the  tongue;  this  is  drawn  up  so  that 
the  lower  surface  becomes  accessible.  The  diseased  part 
of  the  tongue  is  now  hanging  down  and  the  suturing  is 
continued  while  the  tip  is  resected,  bringing  the  surfaces 
in  exact  contact.  Finally  the  excised  part  is  severed  and 
the  remaining  wound  united.  The  two  large  pieces  of 
silk  which  served  to  draw  the  tongue  forward  are  re- 
moved, but  two  of  the  threads  from  the  sutures  are  left 
and  fastened,  one  on  each  cheek,  to  pull  the  tongue  for- 
ward in  case  of  post-operative  oedema.  Liquid  diet 
should  be  prescribed,  which  is  to  be  given  through  a  glass 
tube. 

Large  tubercular  abscesses  of  the  tongue,  especially 
those  on  the  side  and  extending  down  to  the  reflection  of 
the  mucous  membrane  of  the  floor  of  the  mouth,  cannot  be 
operated  upon  as  just  described.  These  should  be  curet- 
ted. Brophy  recommends  application  of  lactic  acid  and 
the  X-ray.  He  says  that  the  results  of  treatment  of 
tuberculosis  of  the  tongue  are  not  gratifying,  and  that 
this  is  primarily  due  to  the  fact  that  the  patient  is  much 
debilitated  by  the  presence  of  tuberculosis  in  other  parts 
of  the  body,  therefore  one  should  be  guarded  in  his 
prognosis. 

6.    Treatment  of  Abscesses  of  the  Salivary  Glands  and 

Duets. 

Abscesses  of  salivary  glands  and  ducts  are  almost  al- 
ways associated  with  salivary  calculi,  which  are  ascer- 
tained and  diagnosed  by  means  of  radiographs.  Surgical 
interference  therefore  is  always  necessary. 


174  ORAL   ABSCESSES 


Abscesses  and  calculi,  which  are  formed  in  the  glan- 
dular ducts,  can  almost  always  be  excised  from  the  inside 
of  the  mouth,  except  in  Wharton's  duct,  which  we  can 
only  trace  as  far  back  as  the  myohyoid  muscle  from  this 
region.  Also  the  sublingual  gland  is  accessible  from  the 
inside  of  the  mouth,  while  the  submaxillary  gland,  how- 
ever, and  the  posterior  part  of  its  duct,  as  well  as  the 
parotid  gland,  can  only  be  reached  by  an  incision  through 
the  skin. 

After  the  mouth  has  been  opened  under 
operation  ether  the  tongue  is  seized  with  a  pair  of 
floor  Tof  tongue  forceps  and  drawn  towards  the 
THE    MOUTH     corner  of.  the  mouth  on  the  healthy  side, 

the  lower  part  turned  up.  The  tongue 
now  can  be  retracted  so  that  we  get  good  access  to 
the  field  of  operation.  Pack  the  pharynx  with  gauze  and 
apply  iodine  for  sterilization.  Ajo.  incision  is  made  half- 
way between  the  f renum  of  the  tongue  and  the  inner  sur- 
face of  the  jaw,  and  parallel  with  the  latter.  The  mucous 
membrane  is  carefully  dissected  away  and  retracted. 
Part  of  Wharton's  duct  is  now  visible,  and  if  it  harbors 
the  stone  it  should  be  dissected  (lingual  nerve  towards 
the  mesial  side).  Split  the  duct  lengthwise  directly  over 
the  stone.  This  is  then  removed,  after  which  a  fine  probe 
may  be  inserted  through  the  ranuncula  salivaris,  over 
which  the  opening  of  the  duct  can  be  closed  with  a  few 
sutures.  If  the  stone,  however,  is  not  found  to  be  in 
this  duct,  or  if  it  had  been  diagnosed  from  the  beginning 
to  be  in  the  sublingual  gland,  we  should  first  ascertain  its 
exact  location  by  puncturing  the  gland  with  a  straight  and 
fine  steel  needle.  If  we  draw  pus  or  feel  hard  resistance 
we  know  that  we  are  near.  The  way  to  the  stone  should 
be  secured  by  a  blunt  instrument  injuring  as  little  of  the 
glandular  substance  as  possible.  A  fine  haemostatic 
forceps  serves  well  for  taking  hold  of  the  stone,  and 
after  it  is  removed  the  pus  should  be  washed  out  with  salt 
solution,  tincture  of  iodine  may  be  applied,  after  which 
the  mucous  membrane  is  closed  by  catgut  sutures.     In 


TREATMENT  175 


the  experience  of  the  author  great  relief  and  speedy  im- 
provement follows  this  operation. 

In  cases  where  the  stone  cannot  be  re- 
of^the01^  nioved  from  the  inside  of  the  mouth,  ex- 

G lands  cision  of  the  whole  gland  is  advisable  to 

prevent  salivary  fistulas.  The  same  is 
true  in  cases  of  extensive  destruction  of  any  of  the  glands. 
If  a  fistula  exists  already  it  is  sometimes  due  to  obstruc- 
tion in  the  excretory  duct,  the  relief  of  which  has  been 
found  to  cause  speedy  healing  of  the  fistula. 

7.    Treatment  of  Systemic  Complications. 

The  important  factor  in  treatment  of  systemic  compli- 
cations is  the  early  removal  of  the  focus.  If  foci  have 
been  in  an  active  state  for  a  considerable  period  of  time 
the  disease  becomes  firmly  fixed,  the  secondary  infection 
may  be  well  established,  and  in  the  persistent  stage  tissue 
destruction  may  have  occurred ;  this  condition  is  beyond 
repair.  Elimination  of  the  focus  then  does  little  in  the 
way  of  repair,  although  it  prevents  reinfection  and  re- 
moves a  septic  condition  which  is  a  great  burden  to  the 
system,  wearing  out  the  organs,  the  duty  of  which  is  to 
protect  the  body  by  destroying  the  bacteria  and  neutral- 
izing the  foreign  ferments  and  protein  poisons. 

If  a  result  is  expected  from  the  removal  of  the  focus  of 
a  disease,  it  is  of  utmost  importance  not  only  to  find  and 
remove  the  primary  focus,  but  also  others,  namely,  the 
secondary  foci  caused  by  hematogenesis  from  the  primary 
focus,  as  these  are  new  factors  which  will  continue  the 
trouble.  A  streptococcus  infection  of  the  tonsils  may, 
for  example,  have  been  the  primary  cause  of  an  endocar- 
ditis or  acute  arthritis,  but  they  also  may  have  produced 
a  streptococcus  infection  in  two  chronic  alveolar  granu- 
lomata  which  heretofore  had  been  caused  by  staphylococci 
albi.  After  the  removal  of  the  tonsils,  the  infection  con- 
tinues from  the  streptococcus  infection  of  the  dental 
granulomata  and  we  fail  to  get  a  cure.  No  time  there- 
fore should  be  lost  in  acute  hopeful  conditions  to  ascertain 


176  ORAL   ABSCESSES 


all  foci,  whether  primary  or  secondary,  and  promptly 
start  in  with  their  radical  removal. 

This,  however,  should  be  undertaken  in  a 
autSnoc-  systematic  way,  and  not  as  one  multiple 
ulation  operation,  as  such  procedure  could,  under 

certain  circumstances  as  we  have  seen, 
bring  positive  harm.  The  surgical  interference  neces- 
sarily inoculates  the  patient  with  a  large  number  of  or- 
ganisms, inducing  an  effect  similar  to  that  of  an  efficient 
vaccine,  with  the  added  advantage  that  the  constant 
supply  is  shut  off  from  the  disturbed  focus.  This  sur- 
gical auto-inoculation  stimulates  the  production  of  anti- 
bodies benefiting  the  patient  after  each  operation,  bring- 
ing about  a  gradual  gain.  It  can  readily  be  seen  that  a 
too  large  inoculation  would  cause  positive  harm, 
especially  in  a  patient  who  is  weakened  and  has  lost  his 
resistance  by  long  standing  disease.  The  removal  of  the 
foci  should,  therefore,  be  carefully  planned;  three  to  six 
days  should  elapse  between  each  operation.  Not  only 
should  foci  in  different  parts  of  the  body  be  removed  at 
different  times,  but  also  foci  in  one  region  should,  if  pos- 
sible, be  operated  on  with  intermission.  In  the  mouth, 
for  example,  abscessed  teeth  should  be  extracted  and 
curetted  one  at  a  time,  leaving  three  to  six  days  between 
each  operation,  and  here  again  I  want  to  impress  the  im- 
portance of  thorough  curettage,  because  it  not  only 
removes  the  principal  part,  the  real  focus,  which  other- 
wise may  continue  to  feed  the  infection,  but  also  surgical 
auto-inoculation  is  wholly  dependent  upon  thorough  dis- 
turbance of  the  focus. 

In  most  diseases  treatment  of  the  secondary  manifes- 
tations is  to  be  undertaken  hand  in  hand  with  the  removal 
of  the  focus,  because  we  can  not  expect  that  pathological 
changes  in  the  new  lesions  disappear  without  the  proper 
care  and  attention.  Medical  therapeutics,  massage,  hy- 
drotherapeutics,  surgical  interference,  rest,  or  exercise, 
fresh  air,  cheerful  surroundings,  regulation  of  diet  and 
improvement  in  digestion  and  assimilation,  all  will  fur- 
ther improvement  and  cure  of  the  disease. 


TREATMENT  177 


restoration  ^ne  °^  ^e  ^ac^ors  which  improves  the 
OF  masti-  patient's  digestive  process,  and  with  it  his 
gating  health  and  strength,  is  proper  mastication 

efficiency  °^  ^*e  ^°°d-  We  cann°t  expect  that  the 
stomach  of  a  weakened  patient,  whom  we 
desire  to  build  up,  will  digest  food  which  has  not  been 
properly  prepared  in  the  mouth.  It  is  therefore  of 
greatest  importance  to  replace  all  teeth,  those  which  have 
been  previously  lost  and  those  which  had  to  be  sacrificed 
to  get  rid  of  a  primary  or  secondary  infectious  focus.  The 
mouth  should  as  soon  as  possible  be  restored  to  its  full 
and  important  physiologic  action  by  plates  or  removable 
bridge  work. 


CHAPTER  XI 


PREVENTION 

Gigantic  studies  have  been  made  both  in  medicine  and 
dentistry  in  the  last  twenty  or  thirty  years.  The  most 
important  advances,  perhaps,  are  those  of  preventive 
medicine  and  hygiene,  and  from  all  the  specialties  of 
medicine  there  is  none  in  which  prevention  is  more  im- 
portant than  in  dentistry.  Disease  of  a  tooth  means 
invariably  loss  of  substance;  whether  it  is  hard  or  soft 
tissue,  restoration  to  normal  is  seldom  possible,  a  decayed 
tooth  will  never  fill  in,  an  inflamed  pulp  will  not  yield 
to  any  treatment,  and  the  result  is  always  loss  of  part  of 
the  tooth  or  of  the  whole  organ.  The  treatment  is  a  re- 
placement of  the  lost  organic  substance  by  inorganic 
material,  metal  or  porcelain,  and  the  result  is  a  com- 
promise of  a  more  or  less  temporary  character. 

The  importance  of  the  oral  hygiene  movement  has  been 
acknowledged  by  the  physician,  the  schools,  and  the  pub- 
lic, and  it  is  general  knowledge  that  teeth  should  be  saved 
for  masticating  purposes  and  that  insufficient  mastication, 
from  lack  of  teeth,  often  causes  malnutrition.  Today, 
however,  there  is  connected  with  oral  hygiene  a  still 
greater  factor  than  saving  teeth  for  mastication;  this  is 
prevention  of  septic  conditions  in  the  mouth.  We  have 
seen  that  the  mouth  is  the  very  gateway  through  which 
disease  may  enter  and  proceed  through  various  channels 
to  almost  any  part  of  the  body.  In  our  practical  hospitals 
and  clinics  we  have  occasion  to  see  patients  where  disease 
is  well  on  the  way,  so  that  it  is  too  late  for  a  cure  of  the 
secondary  chronic  disease;  we  see  a  large  number  of 
patients  where  we  can  stop  disease  by  removing  the  septic 
condition,  and  in  still  others  we  shall  be  able  to  prevent 
septic  oral  foci  by  judiciously  selecting  favorable  cases 


PREVENTION  179 


only  for  root  canal  treatment,  advising  extraction  of  those 
teeth  which  cannot  properly  be  taken  care  of.  Our  great- 
est effort,  however,  should  be  directed  towards  educating 
the  public  to  make  them  realize  the  importance  of  pre- 
serving the  vitality  of  the  tooth  and  prevent  decay,  which 
is  almost  always  the  primary  cause  of  pulp  disease  and 
dental  abscesses.  The  gums  should  be  kept  in  healthy 
condition  so  as  to  prevent  pyorrhoea,  which  is  a  disease 
of  almost  equal  frequency. 

Prevention  of  Secondary  Diseases  from  Oral  Abscesses. 

At  another  place  we  have  discussed  the  privilege  and 
duty  of  the  dentist  to  participate  in  the  diagnosis  of  the 
cause  of  secondary  disease  and  the  aid  in  treatment,  by 
judiciously  and  radically  removing  such  foci,  if  abscesses 
or  other  septic  conditions  are  found  in  the  mouth.  The 
difficulty  in  obtaining  a  speedy  cure  by  the  removal  of 
the  focus  after  the  secondary  disease  has  passed  into  a 
chronic  stage,  has  been  pointed  out  at  various  places,  and 
the  advantage  of  removing  such  foci  for  prevention  is 
therefore  obvious.  Each  individual  mouth  should  be 
examined  most  carefully  by  means  of  instrumentation  and 
radiographs,  and  all  septic  conditions  should  be  radically 
removed.  If  it  seems  advisable  to  treat  these  teeth  in 
a  conservative  way  by  carefully  sterilizing  and  filling  the 
root  canals,  subsequent  examination  by  the  radiograph 
at  regular  intervals  is  indicated  to  note  whether  there  is 
improvement  or  whether  the  condition  is  getting  worse. 
It  may  be  hard  for  a  man  who  has  practised  for  years  the 
saving  of  every  tooth  at  any  cost,  to  make  up  his  mind 
to  advise  extraction  or  expensive  root-canal  treatment  if 
there  is  no  apparent  local  trouble  in  the  mouth,  and  it 
will  be  hard  for  a  patient  to  understand  why  this  or  that 
tooth  which  does  not  ache,  could  be  a  factor  of  present 
or  future  ill-health,  and  should  be  treated  or  removed, 
unless  the  dentist  is  able  to  explain  the  condition  in  a  con- 
vincing manner,  which  can  only  be  based  upon  a  thorough 
understanding  of  the  condition.  But  he  who  does  not 
tolerate  septic  conditions  in  his  patient's  mouth  practises 


180  ORAL   ABSCESSES 


good  dentistry  as  far  as  the  teeth  are  concerned,  and  most 
excellent  preventive  medicine  from  the  standpoint  of  the 
whole  body. 

Prevention  of  Periapical  Infection. 

The  question  whether  or  not  abscesses  on  devitalized 
teeth  can  be  prevented  has  not  yet  been  entirely  solved. 
The  men  (Ulrich*)  who  believe  that  these  abscesses  are 
caused  principally  by  haematogenous  infections  of  the 
periapical  area  of  pulpless  teeth,  which  represents  tissue 
of  lower  resistance,  think  that  it  does  not  matter  how  well 
the  root  canals  are  filled,  abscesses  may  be  caused  in  any 
case,  if  there  are  infectious  foci  in  other  parts  of  the  body, 
which  cause  a  mild  bacteremia.  They  claim  that  it  is 
especially  the  streptococcus  to  which  the  lesion  may  be 
attributed  and  look  at  most  apical  abscesses  as  secondary 
infections.  However,  we  need  not  search  for  very  remote 
modes  of  infection  when  there  are  other  causes  nearer  at 
hand.  If  we  consider  the  anatomy  and  pathology  of  the 
dental  pulp,  if  we  remember  how  hard  it  is  to  render  asep- 
tic the  root  canal,  the  dentinal  tubules  and  the  apical  fora- 
mina, and  how  often  careless  methods  of  technique  are 
employed,  we  find  the  causes  may  be  practically  obvious. 
However,  I  do  not  doubt  that  in  some  instances  abscesses 
start  as  a  secondary  infection,  and  furthermore,  that 
subacute  attacks  of  abscesses  which  have  been  in  the 
quiescent  stage  of  inflammation  for  many  years  may  per- 
haps be  explained  in  this  way,  although  here  again  we 
have  other  factors  to  consider. 

RADIO-  It  is  well  to  radiograph  a  tooth  before 

GRAPHIC  undertaking   to   treat   a   root   canal,   no 

DIAGNOSIS  matter  what  condition  it  is  in.  Abnormal 
before  ROOT  formation  of  the  roots  and  obstructions 
CANAL  such  as  deposits  of  secondary  dentine  and 

tment  pulpstones  can  in  this  way  be  determined 
beforehand,  and  the  patient  and  the  dentist  save  much 
time  and  expense  if  it  is  determined,  whether  or  not 
we  can  mechanically  achieve  a  perfect  result. 

*  Ulrich,  Henry  L. :  The  Blind  Abscess.     Journal  of  the  American  Medical  As- 
sociation, November  6,  1915,  p.  1619. 


PLATE      LXXiV 


Fig.  273. — Microphotograph  of  the  apex  of  a  tooth  showing  multiple 

foramina. 

Specimen  by  author  and  stained  with  Mallory  's  Phosphotungstic 
acid  and  Hematoxylin. 


PREVENTION'  181 


Grieves*  points  out  that  arsenic  used  for 
FOR  Erulf^SBA  devitalization  of  a  pulp  is  very  apt  to 
extirpation  cailse  necrosis  in  the  periapical  tissue  on 
account  of  its  vascularity,  the  drug  being 
absorbed  by  the  pulp.  Pressure  anaesthesia  with  novo- 
cain or  cocaine  as  first  described  by  Professor  Edward  C. 
Briggs  of  Boston,  is  of  greatest  value  for  pulp  extirpa- 
tion. Local  anaesthesia  with  novocain  suprareninf  is 
also  very  excellent,  and  many  times  the  only  method  that 
gives  results,  as  in  cases  of  diseased  pulps  with  persisting 
nerve  fibres  or  partly  extirpated  pulps.  General  anaes- 
thesia is  not  recommended  except  in  front  teeth  where 
the  procedure  is  comparatively  simple. 

If  a  pulp  is  infected  or  disturbed  by  sur- 
pulpPLETE  gi-cal  interference,  it  strangles  itself  at 
EXTIRPATION  ^ne  apical  foramen  on  account  of  the  hy- 
peremia produced.  It  is  therefore 
important  to  remove  every  particle  of  it,  or  later  it  will 
become  a  source  for  periapical  infection. 

In  pulp  extirpation  a  fine  broach  should  be  inserted  as 
far  into  the  root  canal  as  possible  so  that  the  entire  pulp 
is  removed  at  once.  A  fine  wire  with  a  loop  should  then 
be  inserted  with  the  mild  antiseptic  dressing,  and  another 
radiograph  should  be  taken  to  find  out  whether  we  have 
reached  the  end  of  the  root. 

If  the  root  canal  is  not  large  enough  to 
andAenlarg-  a^ow  eas^  Passage  to  its  end,  and  if  dis- 
ING  the  "  eased  oi"  healthy  tissue  remains,  this 
canal  should  be  taken  care  of  by  the  sulphuric 

acid  or  sodium  potassum  method.  Both 
of  these  drugs  are  valuable  for  root  canal  work,  but  care 
should  be  taken  not  to  force  any  through  the  apical  fora- 
men. The  sulphuric  acid  should  be  neutralized  with 
sodium  bicarbonate;  both  drugs  are  best  used  in  Luer 
syringes  with  root  canal  hub.  The  sodium  potassium 
paste  is  used  on  smooth  broaches;  its  great  affinity  for 
organic  matter  draws  the  drug  through  obstructed  places, 

*  Grieves,  Clarence  J. :  Dental  Cosmos,  October,  1915,  p.  1118. 
t  Thojia,  Kurt  H.:  Oral  Anaesthesia,  p.  107. 


182  ORAL   ABSCESSES 


making  passage  way  for  the  broach.  The  result,  however, 
depends  a  great  deal  upon  patient  and  continued  instru- 
mentation. The  Rhein  picks  are  the  most  valuable  in- 
struments for  this  purpose.  The  strong  caustic  alkali 
which  is  formed  by  this  process  should  be  neutralized  by 
sulphuric  acid,  and  this  in  turn  by  sodium  bicarbonate. 
An  important  factor  in  root  canal  operations  is  easy 
access,  for  the  crown  of  the  tooth  should  be  so  reduced 
as  to  allow  straight  entrance  into  the  canals. 

Failure  of  achieving  the  desired  results  in 
medicatIon     root-canal  operations  has  gradually  led  to 

the  use  of  highly  oxidizing,  tissue  obstruc- 
ting drugs  with  great  penetrating  power,  in  the  age  when 
older  antiseptic  methods  have  almost  entirely  yielded  to 
good  surgery,  and  where  it  is  an  important  principal  to 
destroy  as  few  cells  as  possible,  and  where  we  know  that 
any  cell  which  is  rendered  necrotic  adds  only  another 
place  where  infection  may  find  media  of  its  liking. 
Drugs,  such  as  formaldehyde  and  all  its  numerous  prepa- 
rations, should  not  be  placed  into  a  root  canal  under  any 
condition.  Formaldehyde  preparations  should  only  be 
used  as  the  first  dressing  upon  a  putrescent  pulp,  placed 
into  the  pulp  chamber,  and  covered  with  cotton  saturated 
in  petrol  oil  or  with  temporary  stopping,  as  the  case  re- 
quires. After  the  pulp  has  been  extirpated,  this  drug 
should  no  longer  be  applied  into  the  pulp  chamber  nor 
into  the  root  canal,  as  it  would  penetrate  through  the 
foramen  and  do  harm  to  the  periapical  tissue.  Zinc 
chloride,  copper  sulphate,  concentrated  phenol,  tri- 
chloracetic acid  are  other  root-canal  drugs  of  great  tissue 
destroying  action.  Their  use  as  well  as  the  use  of  sul- 
phuric acid  and  sodium  potassium  for  root-canal  cleaning 
should  be  carefully  controlled,  and  great  care  should  be 
taken  to  confine  their  action  to  the  root  canal.  Gr.  V. 
Black*  describes  at  length  experiments  made  by  appli- 
cation of  the  different  drugs  for  use  in  root  canal  treat- 
ment. The  different  medicaments  were  applied  to  the 
skin  on  cotton  in  small  rubber  cups,  held  in  position  by 

*  Black,  G.  V. :  Special  Dental  Pathology,  pp.  291-298. 


PLATE      LXXV 


Fig.  274. — Microphotograph  of  the  end  of  a  root. 

A,  showing  root  filling  extending  into  a  remnant  of  pulp  which 

may  give  a  symptom  of  pain  which  often  is  mistaken  for  the 

pain  caused  when  emerging  through  the  apical  foramen. 

B,  Necrosed  area  of  the  dentine.     D,  Pulp  remnant. 

C,  Secondary  dentine  filling  the  canal. 

Specimen  prepared  by  the  author.     Stained  by  Mallory's 
Phosphotungstic  acid  and  Hematoxylin. 


PREVENTION 


court  plaster.  Oil  of  cloves  and  Blackwood  creosote  each 
produced  practically  no  inflammation,  Black's  1,  2,  3  only 
slight  irritation,  oil  of  cinnamon  a  large  blister,  creosol 
and  formalin  in  each  instance  a  very  deep  inflammation 
which  was  painful  and  so  unbearable  that  it  had  to  be 
removed  after  seven  hours ;  the  tissue  formed  no  blister 
but  was  of  yellowish  color  as  though  it  would  slough 
away ;  needles  could  be  stuck  into  the  tissue  one-third  of 
an  inch  before  sensation  was  felt.  Six  weeks  later  a  scar 
was  visible  which  looked  as  though  the  area  had  been 
burned.  It  is  evident  that  such  an  injurious  drug  should 
not  be  sealed  into  root  canals. 

To  avoid  injury  of  the  periodontal  membrane  and  bone 
surrounding  the  apex  of  the  tooth,  the  operator  should 
put  his  effort  into  perfecting  his  technique  rather  than 
relying  on  strong  drugs  to  sterilize  what  he  neglected  to 
remove.  Mild  antiseptics  and  anodines  are  sufficient  as 
dressings  in  most  cases,  ionic  application  of  iodine  will 
take  care  of  bacteria  in  dentinal  tubules  and  accessory 
foramina,  and  if  a  healthy  condition  cannot  be  obtained 
by  mild  medication,  the  cause  is  to  be  looked  for  outside 
the  tooth.  If  a  radiograph  was  not  taken  beforehand,  it 
is  now  time  to  find  out  the  condition  of  the  periapical 
tissue,  and  in  most  cases  it  will  be  found  that  the  reason 
of  not  making  any  headway  is  due  to  a  granuloma  or 
chronic  abscess,  a  lesion  which  does  not  yield  to  medicinal 
treatment.     Mild  antiseptics  of  reputation  are : 

Black's  1,  2,  3. 

01.  cassiae 1  part 

Thenolis   2  parts 

01.  Gaulteriae 3  parts 

Mx  the  oils  and  add  melted  crystals  of  phenol. 

Buckley's  Modified  Phenol. 

Mentholis   gr.  xx 

Thymolis gr.  xl 

Phenolis    f 3  iii 


184  OKAL   ABSCESSES 


Ionic  medication  has  already  been  consid- 
medicatson  ere(^  -^or  treatment  of  periodontitis.  Zinc 
chloride  and  copper  sulphate  should  not 
be  used  for  sterilization  of  dental  structures  on  account 
of  their  tissue  destroying  action,  upon  which  some  men 
base  the  treatment  of  the  apical  granuloma.  This  is  be- 
lieved to  be  dissolved  by  this  method  so  that  it  can  be 
resorbed  by  the  tissue.  Such  applications,  however,  also 
destroy  the  periodontal  membrane,  and  as  we  have  seen 
that  the  success  of  root  canal  treatment  depends  upon 
preservation  of  this  most  important  structure,  it  would 
be  unwise  to  apply  an  agent  which  has  exactly  the  oppo- 
site effect. 

Iodine  ions  are,  however,  to  be  recommended  for  root 
canal  or  rather  dentine  sterilization.  Tincture  of  iodine 
3y2  per  cent,  or  aqueous  solution  of  iodine,  a  recent  prepa- 
ration without  the  irritating  action  of  the  alcohol,  is 
applied  into  the  root  canal  by  means  of  a  Luer  syringe. 
The  negative  pole  is  applied  to  a  platinum  broach,  with 
cotton  saturated  in  the  same  solution  attached,  the  posi- 
tive pole  is  placed  under  the  rubber  dam  in  the  form  of  a 
sponge  electrode,  or  held  in  the  hand.  The  circuit  of  a 
direct  current,  reduced  by  a  special  rheostat  (there  are 
several  well  made  ionization  machines  in  the  market)  and 
measured  by  a  milliampere  meter  is  now  closed  and  the 
amount  is  gradually  increased  until  from  %  to  3  milliam- 
pere is  used.  The  treatment  should  be  applied  for  ten 
minutes  in  each  canal.  Iodine  should  be  added  from 
time  to  time,  as  it  is  used  up  quickly,  which  is  indicated 
by  the  white  color  of  the  peripheral  part  of  the  dressing. 
After  ionic  medication  with  iodine  the  pulp  chamber 
should  be  washed  out  with  alcohol  or  acetone  to  remove 
the  brown  stain.  A  mild  aseptic  dressing  is  inserted  and 
the  canals  filled  at  another  sitting. 

The  most  important  factor  which  has  to  do  with  poor 
root-canal  filling  and  following  periapical  infection  is 
unsuccessful  dehydration.  Acetone  should  be  applied  by 
means  of  Luer  syringe  and  broach,  and  dried  out  with 
hot  compressed  air.     An  electric  root-canal  dryer  is  then 


PLATE      LXXVI 


Fig.  278 


Fig.  275 


Fig.  279 


Fig.  280 


Fig.  276 


Fig.  281 


Fig.  282 


Fig.  277 


Figs.  275,  276  and  277. — Radiographs  showing  the  process  of  root  canal  treatment. 

Fig.  275,  shows  a  wire  which  was  inserted  to  see  whether  the  apex  was  reached. 

Fig.  276  shows  an  unsuccessful  root  canal  filling.     Fig.  277  the  final  filling. 

Figs.  278,  279  and  280. — Radiograph  No.  278,  showing  two  teeth  not  filled  to  the  end. 

Fig.  279,  radiographs  with  wires  inserted.     Fig.  280  shows  the  canal  fillings. 
Figs.   281,  282.     Radiograph  No.   281   shows   "corkscrew"   filling  which   was   replaced 

by  filling  seen  in  Fig.  282. 


PLATE      LXXVII 


Fig.  283 


Fig.  284 


Fig.  285 


Fig.  285. — On  left  root  treatment  attempted  through  small 

cavity,  the  broach  does  not  go  around  the  curve.     On  right 

mesio-occlusial  cavity  cut  extensively,  so  as  to  get  proper 

access  to  canals. 

Fig.  284  and  285. — Specimen  of  bent  and  curved  roots,  the 
root  canals  of  which  would  be  hard  to  treat  and  fill. 


PREVENTION  185 


inserted  and  if  used  for  the  first  time  the  operator  mil  be 
surprised  to  hear  a  sizzling  noise,  indicating  that  there 
was  still  some  moisture  left.  The  heat  is  applied  until 
the  patient  feels  the  warmth.  For  root-canal  filling 
the  author  prefers  the  chloroform-resin-gutta-percha 
method.*  The  chloroform  and  resin  (d.i  to  gr.  iv) 
is  best  applied  into  the  canal  by  use  of  an  ordinary  Luer 
Q  syringe ;  with  a  smooth  broach  carefully  remove  all  air 
bubbles.  Select  a  sterile  gutta-percha  cone  or  point  and 
pump  it  into  the  canal  forty  times.  The  chloroform  dis- 
solves the  gutta  percha,  which  is  forced  into  the  fine  canals 
and  foramina  by  the  pumping  action.  Other  cones  follow 
the  first  until  the  canal  is  filled,  when  the  filling  is  con- 
densed with  a  root  canal  condenser.  This  method  has 
several  advantages;  the  most  important  ones  are  that 
newly-formed  chloro-percha  can  be  forced  into  the  finest 
canals  without  the  evaporation  which  spoils  the  result  in 
other  methods,  and  that  the  excess  forced  through  the 
foramina  is  not  a  sharp  point  projecting  into  the  peri- 
apical tissue,  but  a  soft  paste  which  caps  the  apex,  so  to 
speak,  adapting  itself  on  its  surface.  A  radiograph  is 
taken  immediately,  and  in  case  the  filling  does  not  reach 
to  the  apex  it  can  be  removed  before  it  has  hardened,  when 
the  same  process  is  repeated  until  the  filling  is  satis- 
factory. 

Sterilization  of  the  instruments  and 
Ti on  and  aseptic  methods  cannot  be  too  strongly  in- 
ASEPSiS  sisted  upon.     If  we  consider  that  the  bac- 

teriologist sterilizes  his  smooth  platinum 
needle  most  carefully  in  the  flame  before  he  uses  it  for 
inoculation  of  an  artificial  medium,  we  must  realize  how 
much  more  important  it  is  to  sterilize  in  a  most  scrupulous 
manner  rough  instruments,  such  as  broaches,  so  as  not  to 
inoculate  the  human  tissue.  All  root-canal  instruments 
should  be  immersed  in  alcohol,  or  in  phenol  first  and 
alcohol  secondly,  each  time  before  they  are  used.  The 
field  of  operation  should  be  properly  prepared  by  use  of 

*  Calahan,  J.  E. :   Eesin  Solution  in  Eoot  Canals.     Items  of  Interest,  August, 
1915,  p.  579. 


186  ORAL   ABSCESSES 


rubber-dam  and  scrubbing  of  the  projecting  teeth  with 
10%  formaldehyde,  which  is  dried  off  by  means  of  air. 
If  cotton  dressings  are  used  for  root  canal  work,  or  if 
broaches  wound  with  cotton  are  used,  a  number  properly 
prepared  and  sterilized  should  be  kept  on  hand.  The 
cavity  should  be  most  carefully  sealed  after  each  treat- 
ment to  keep  saliva  from  entering. 
summary  OF  ^e  important  factors  which  should  be 
important  borne  in  mind  in  operations  of  pulp  re- 
FACTORS  TO  moval,  root-canal  work  and  filling,  are,  in 
prevent  short,  the  following : 

periapical  i    Diagnose    the    condition    first    by 

means  of  a  radiograph. 

2.  Treat  only  cases  which  promise  a  good  result. 

3.  Observe  strict  aseptic  precautions. 

4.  Extirpate  all  pulp  tissue. 

5.  Avoid  injury  and  necrosis  of  the  periapical  tissue 
as  caused  by  the  use  of  certain  irritating  drugs. 

6.  Avoid  infecting  of  the  periapical  tissue  by  instru- 
mentation. 

7.  If  a  root  canal  does  not  yield  treatment  in  a  short 
time  and  no  radiograph  was  taken  in  the  first  place,  take 
one  now  with  an  indicator  in  the  root  canal  and  find  out 
what  is  wrong. 

8.  Fill  the  root  canals  to  the  very  end  and  ensure  a 
successful  operation  by  means  of  another  radiograph. 

Prevention  of  Devitalised  Teeth. 

devitaliza-      Our  knowledge  of  the  etiology  and  com- 

tion    FOR         plications  of  alveolar  abscesses  and  reali- 

SrSSi'wiyAMrk  zation  of  the  uncertainty  of  root-canal 
DENTINE  and  .  •*  .j     ,, 

prostheses  fillings  should  impress  in  our  minds  the 
notjusti-  seriousness  of  pulp  extirpation.  He 
fied  wh0  extirpates  the  pulp  of  one,  two  or 

more  teeth  to  restore  masticating  efficiency  by  bridge 
work  renders  poor  services  if  granulomata  develop  on  the 
devitalized  teeth,  which  are  apt  to  endanger  the  patient's 
health.     A  pulp  for  such  or  similar  purposes  should  not 


PREVENTION"  187 


be  sacrificed  except  after  the  most  careful  consideration 
and  prognostic  study  of  the  roots  and  root  canals  by 
means  of  radiographs.     Prosthetic  appliances  should  be 
constructed  which  do  not  require  devitalization  of  healthy 
teeth,  and  our  efforts  should  be  in  the  direction  of  devis- 
ing reconstruction  work  which  is  not  destructive  to  the 
remaining  hard  or  soft  tissues  of  the  mouth. 
tr e ATM E  NT        Hyperemia  and  exposures  are  frequently 
OF  hyperemia  brought  about  when  excavating  cavities 
sures  of°"        ^  insufficient  attention  is  paid  to  the 
THE  pulp  TO      approach  to  the  pulp.     The  pulp  horns 
prevent  de-     are  especially  liable  to  become  acciden- 
vitalization     tally  involved.    Large  metal  fillings  are 
liable  to  cause  hyperemia  because  they  are  good  conduc- 
tors of  heat  and  cold.     A  nonconductor  should  be  placed 
into  the  deepest  parts  of  the  cavity  beneath  the  filling. 
A  pulp  in  the  state  of  active  hyperemia  can  almost  always 
be   saved   if   the   irritating   causes   are   removed.     The 
mildest  anodines  should  be  applied,  such  as  oil  of  cloves 
or  modified  phenol  slightly  warmed,  until  the  irritation 
has  subsided,  when  the  same  treatment  as  for  pulp  cap- 
ping is  indicated.    Pulp  capping  is  performed  over  deep 
decayed  areas  which  reach  very  close  to  the  pulp,  and 
where  there  is  danger  of  making  an  exposure  if  excavation 
is  continued.    The  action  then  is  that  of  preservation.    In 
actual   small   exposures   made   by   excavators   in   fully 
formed  teeth  in  cases  where  the  pulp  has  previously  given 
no  symptoms  of  inflammation,  and  in  exposures  of  teeth 
the  apical  foramen  of  which  is  wide  open,  with  pulp  nor- 
mal or  very  slightly  inflamed,  we  may  attempt  to  save 
the  pulp  by  the  so-called  capping  method.    The  patient, 
however,  should  be  informed  of  the  doubtful  outcome  of 
the  undertaking.    If  there  is  slight  hyperemia  of  the  pulp, 
an  anodine  such  as  modified  phenol  or  oil  of  cloves  should 
first  be  applied,  sealing  it  into  the  tooth  with  quicksetting 
cement  (not  gutta  percha)  for  one  week.    At  the  second 
visit  zinc  oxide  and  eugenol,  mixed  to  a  thin  paste,  is 
slightly  coaxed  over  the  exposed  area ;  this  is  covered  with 
a  layer  of  quick-setting  cement.     All  depends  upon  per- 


188  OEAL   ABSCESSES 


feet  asepsis,  skillful  manipulation  and  prevention  of  any 
pressure  or  irritation.  A  temporary  filling  may  be  used 
until  the  result  is  made  sure  of. 

early  treat-  The  prevention  of  hyperemia,  which  leads 
me  NT  of  to  other  diseases  of  the  pulp,  is  best  ac- 

c aries  and  complished  by  filling  the  cavities  when 
prophylaxis  smaii  and  shallow,  or  better  still,  in  con- 
trolling decay  by  prophylactic  treatment.  This  is  also 
prevention  in  the  highest  degree  against  alveolar  abscesses 
and  its  many  and  dangerous  complications.  The  teaching 
to  the  public  of  oral  hygiene,  which  first  was  principally 
undertaken  to  combat  the  loss  of  masticating  efficiency 
and  its  sequels,  poor  digestion,  and  ill-health,  has  now 
grown  to  a  still  greater  importance,  namely :  the  preven- 
tion of  systemic  diseases  of  the  gravest  nature  to  which 
the  unsuspecting  individual  is  liable  to  fall  prey.  With 
this  point  in  view,  the  dentist  should  educate  the  public 
to  the  far-reaching  meaning  of  preventive  dentistry,  and 
offer  his  patients  prophylactic  treatment  at  such  inter- 
vals as  seem  necessary  for  each  individual  case,  and  teach 
each  individual  how  to  keep  the  teeth  in  good  condition 
by  suggestions  as  to  a  suitable  diet  and  practical  demon- 
strations of  how  to  take  care  of  teeth  and  gums  at  home. 


Fig.  288 


Fig.  2i 


Figs.  286,  287,  288  and  289. — Left  and  right  side  view  and  occlusial  view  of  upper 
and  lower  jaw  of  a  patient's  teeth  who  had  the  four  first  molars  extracted  when  sixteen 
years  of  age.     The  four  illustrations  show  the  condition  when  the  patient  was  thirty -five 

years   of   age. 

Reproduced  ~by  the  courtesy  of  Dr.  Eugene  H.  Smith. 


CHAPTER  XII 


THE  TRUE  VALUE  OF  A  TOOTH 

Dean  Smith,  of  Harvard  University  Dental  School,  in 
his  timely  paper  read  before  the  First  District  Dental 
Society  of  the  State  of  New  York,  said:  "We  all  know 
how  difficult  it  is  to  adjust  material  values.  How  much 
more  difficult  it  is  to  adjust  physiological  values,  in  the 
misjudging  of  which  the  happiness,  health,  and  frequently 
the  life  of  the  people  is  jeopardized!"  It  is  indeed  diffi- 
cult to  place  the  right  value  on  a  tooth;  the  judgment 
depends  a  good  deal  on  education,  education  of  the  dentist 
and  education  of  his  patients.  The  value  of  a  healthy 
tooth  in  good  occlusion  is  the  easier  to  determine ;  it  cer- 
tainly cannot  be  overestimated,  but  if  a  tooth  is  affected 
by  any  of  the  various  dental  diseases,  there  arises  a  great 
difference  of  opinion.  Among  the  various  pathological 
conditions  I  shall  consider  only  those  we  are  especially 
concerned  with  in  this  book,  namely,  the  oral  abscesses  and 
systemic  diseases  which  are  caused  by  them.  One  cannot 
place  too  low  a  value  on  a  devitalized  tooth  if  it  causes 
conditions  which  endanger  the  patient's  health. 

The  tooth  which  is  the  most  frequent  cause  of  abscesses 
is  the  first  permanent  molar.  This  tooth,  which  plays 
such  an  important  part  in  the  health,  decays  under  our 
very  eyes  in  children  who  have  the  best  of  care,  unless  the 
fissures  are  carefully  filled  as  soon  as  the  gum  has 
shrunken  away  from  the  occlusial  surface.  In  the  poor, 
who  do  not  care  for  their  teeth  except  if  so  forced  by  pain, 
this  tooth  is  almost  always  a  ruin  when  it  comes  under 
our  observation,  and  its  pulp  is  invariably  diseased  and 
very  often  periapical  infection  has  already  set  in.  The 
value  of  this  tooth  sinks  then  from  the  highest  mark  to 


190  ORAL  ABSCESSES 


the  lowest  level.  Such  badly  decayed  teeth  are  contin- 
uous expenses,  as  they  would  have  to  be  filled  and  refilled 
and  finally  crowned,  and  would  be  sure,  sooner  or  later, 
to  cause  periapical  infection.  The  poison  which  dis- 
charges into  the  system  from  such  a  focus  only  lowers 
the  child's  resistance  to  various  illnesses,  and  hampers 
the  development  of  the  body,  but,  worse  than  all,  may 
cause  systemic  diseases  of  the  gravest  nature  from  which 
recovery  may  be  impossible.  How  much  better  is  extrac- 
tion in  such  cases ;  the  twelve-year  molars  will  move  for- 
ward into  place,  and  while  it  would  not  always  result  in  an 
ideal  condition,  the  condition  which  the  orthodontist  calls 
" perfect  occlusion,"  it  would,  if  symmetrically  carried 
out,  be  just  as  good  as  what  the  average  person  has ;  per- 
sonally, I  would  say  infinitely  better,  because  a  first  molar 
with  periapical  infection  would  have  to  be  extracted 
sooner  or  later ;  it  is  only  a  matter  of  time ;  and  when  ex- 
tracted in  later  life  it  will  leave  a  space  which  cannot  then 
be  filled  in  by  nature,  the  second  molars  having  been  firmly 
fixed  in  the  bone  at  that  period  of  life ;  for  the  patient  the 
result  is  worse  from  any  point  of  view :  that  of  occlusion, 
masticating  efficiency,  chance  of  systemic  infection,  and 
loss  of  time  and  money. 

The  saving  of  teeth  in  children  should  be  of  preventive 
nature,  which  is  the  only  safe  way  of  securing  and  keep- 
ing normal  occlusion;  but  if  it  is  too  late  for  prevention, 
we  must  be  satisfied  with  the  next  best  healthy  condition. 
The  results  obtained  from  symmetric  extraction  of  the 
badly  decayed  permanent  first  molars  are  very  satisfac- 
tory if  undertaken  before  the  age  of  twelve ;  the  occlusion 
is  in  the  majority  of  cases  very  good,  as  has  been  named 
" sufficient  occlusion"  by  Dean  Smith,  a  term  which  ex- 
presses the  condition  fully.  Figures  286  to  293  show 
models  of  two  patients  who  had  the  first  permanent  molars 
extracted  at  the  proper  age  on  account  of  extensive  decay, 
and  the  results  are  gratifying.  These  illustrations  have 
been  reproduced  with  Dr.  Smith's  consent  from  his 
already  mentioned  paper.  While  I  want  it  clearly  under- 
stood that  I  do  not  believe  in  the  wholesale  extraction  of 


PLATE      LXXIX 


Fig.  290 


Fig.  291 


Fig.  292 


Fig.  293 


Figs,  290  and  291. — Left  and  right  view  of  the  teeth  of  a  boy  aged  thirteen.  The 
right  lower  first  molar  is  half  decayed,  pulp  involved,  apical  foramina  open.  The  left 
lower  first  molar  has  an  exposed  pulp.  The  upper  first  molars  are  decayed.  All  the 
first  molars  were  extracted,  no  appliances  had  been  used  and  already  after  three  years 
the  good  result  shown  in  Figs.  292  and  293  were  obtained. 

Reproduced  by  the  courtesy  of  Dr.  Eugene  H.  Smith. 


TRUE  VALUE  OF  A  TOOTH  191 

children's  teeth,  and  that  neither  Dr.  Smith  nor  I  would 
advise  the  above  treatment  except  in  cases  where  the  first 
molars  are  in  hopeless  condition,  I  would  say  this:  that 
I  for  one  should  much  prefer  to  own  any  of  the  mouths 
shown  in  these  pictures  with  only  "sufficient  occlusion" 
of  twenty-eight  healthy  teeth,  than  an  ideal  occlusion 
with  a  number  of  devitalized  teeth  and  arthritic  joints. 

The  value  of  healthy  teeth  is  so  inestimably  high  that 
every  effort  should  be  made  to  preserve  them.  A  devital- 
ized tooth  diminishes  greatly  in  value  if  an  abscess  is 
formed  at  its  roots,  but  when  it  becomes  a  focus  of  ill- 
health  and  disease  in  other  parts  of  the  body,  its  value 
becomes  decidedly  negative  and  its  ownership  a  curse. 


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196  OEAL   ABSCESSES 


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Sawyer,  A.  J.  Oral  Sepsis  as  the  Cause  of  General  or  Systemic  In- 
fection, and  the  Dentist's  Responsibility,  (see  The  Dental 
Cosmos,  March,  1915,  p.  272.) 

Schamberg,  M.  I.  Dentistry,  a  Blessing  and  a  Curse,  (see  Journal 
of  Allied  Dental  Association,  December,  1915,  p.  418.) 

Schuster,  Ernst.  Die  Sektion  der  Zahnwurzel  eine  Operations- 
methode  zur  Entfernung  abgebrochener  Instrumente  aus 
Wurzelkanalen.  (Deutsche  Monatsschr.  fur  Zahnheilkunde, 
January,  1913,  p.  43.) 

Schwabe.  Beziehungen  zwischen  Augen  und  Zahnkkrankheiten. 
(Deutsche  Monatsschr.  filr  Zahnheilkunde,  June,  1914,  p. 
401.) 

Smith,  A.  H.  Some  Studies  of  the  Jaws  in  Health  and  Disease. 
(see  The  Dental  Cosmos,  August,  1913,  p.  765.) 

Smith,  E.  H.  The  Value  of  a  Tooth.  (see  The  Journal  of  Allied 
Dental  Societies,  September,  1915,  p.  331.) 

Steinharter,  E.  C.  Gastric  Ulcer  Experimentally  Produced.  (Bos- 
ton Medical  and  Surgical  Journal,  May  11,  1916.) 

Acute  Arthritis  Experimentally  Produced  by  Intravenous 
Injection  of  the  Staphylococcus  Pyogenes.  (Boston  Medical 
and  Surgical  Journal,  July  13,  1916.) 

Storck,  J.  A.  Teeth  as  a  Factor  in  Digestive  Diseases  and  Dis- 
orders, (see  New  Orleans  Medical  and  Surgical  Journal, 
January,  1904,  p.  497.) 

Straussberg,  M.  Successful  Treatment  of  Apical  Abscesses  by  Ioni- 
zation,    (see  Dental  Items  of  Interest,  April,  1915,  p.  259.) 


200  ORAL   ABSCESSES 


Streitmann,  W.  H.  Oral  Sepsis  as  Kelated  to  Systemic  Disease,  (see 
Items  of  Interest,  December,  1915,  p.  930.) 

Stueeidge,  Ernest.  Dental  Electro  Therapeutics.  (Philadelphia: 
Lea  &  Febiger.) 

Teague,  B.  H.  The  Eecognition  of  Systemic  Disturbance  in  the  Treat- 
ment of  Oral  Lesions,  {see  The  Dental  Cosmos,  April,  1915, 
p.  428.) 

Thoma,  Kurt  H.     Oral  Anaesthesia.     (Boston:  Hitter  &  Flebbe.) 

Oral  Anaesthesia  with  Special  Eeference  to  Surgical  Op- 
erations for  Chronic  Alveolar  Abscesses,  (see  American 
Journal  of  Surgery,  Vol.  I,  No.  3,  April,  1915.) 

Oral  Abscesses,  (see  Journal  of  the  Allied  Dental  Socie- 
ties, March,  1916.) 

Thomas,  J.  D.  The  Effects  of  Prolonged  Treatment  and  Persistent 
Retention  of  Diseased  Teeth,  (see  Items  of  Interest,  August 
1912,  p.  617.) 

Thomson,  Sir  St.  Clair.  Diseases  of  the  Nose  and  Throat.  (Lon- 
don: D.  Appleton  &  Co.) 

Ulrich,  H.  L.  Streptococcicosis.  (see  Journal-Lancet,  November, 
1915.) 

The  Blind  Dental  Abscess.  (see  Journal  of  American 
Medical  Association,  November,  1915,  Vol.  LXV,  p.  1619.) 

Some  Medical  Aspects  of  Certain  Mouth  Infections,  (see 
Dental  Review,  December,  1914.) 

Van  Doorn,  J.  W.  Relation  of  Dental  Lesions  to  Insomnia  and  Nerve 
Strain,     (see  The  Dental  Cosmos,  June,  1909,  p.  677.) 

Vaughan,  V.  C.  Die  Phenomena  der  Infektion  und  Ergebuisse  der 
Immunitatsforschung  Experimentellen  Therapie,  Bakteri- 
ologie  und  Hygiene.  (see  Fortsetzung  des  Jahresberichts 
uber  die  Ergebuisse  der  Immunitatsforschung.) 

Vaughan,  Walter,  Victor  C,  and  Victor  C,  Jr.  Protein  Split 
Products  in  Relation  to  Immunity  and  Disease.  (Lea  & 
Febiger.) 

Wallace,  J.  Sim,  London.  Dental  Diseases  in  Relation  to  Public 
Health.  (Publishing  Office  of  The  Dental  Record,  1914.) 
(Deutsche  Monatsschr.  fur  Zahnheilkunde,  June,  1914.) 

Williger,  Fritz.  Zahnarztliche  Chirurgie,  Berlin.  (Leitfaden  der 
Praktischen  Medizen,  Band  I,  1910.) 

Young,  J.  H.  Tonsillectomy  as  a  Therapeutic  Measure  in  the  Treat- 
ment of  Chorea  and  Endocarditis,  (see  Boston  Medical  and 
Surgical  Journal,  September,  1915,  p.  356.) 

Zilz,  Juljan.  Zur  Klinik  und  Pathologischen  Anatomie  der 
Speichelsteine.  (see  Zeitschrift  fur  Mund-und  Kierfer- 
chirurgie  und  Oreuzgebiete,  Erster  Band,  Erstes  Heft,  p.  32.) 


INDEX  OF  ILLUSTRATIONS 


PLATE 


FACING 
PAGE 

I      Fig.  1.     Predynastic  Egyptian  Skull,  showing  loss  of  bone  due 

to   Abscess    14 

Fig.  2.     Occlusial  View  of  Upper  Jaw  of  same  Skull 14 

II       Fig.  3.     Prehistoric    Peruvian    Skull,   with   loss    of   bone   from 

acute  abscessed  condition 15 

III       Fig.  4.     Apical,  Lateral  and  Interradial  Abscess 18 

IV      Figs.  5  and  6.     Eadiographs  of  Abscesses  caused  by  Trauma. . .  20 
Figs.  7  and  8.     Eadiographs  showing  Treatment  of  Case  in  Fig.  5  20 
Figs.  9,  10  and  11.     Eadiographs  of  Abscesses  involving  neigh- 
boring teeth  20 

V      Figs.  12  and  13.     Abscesses  due  to  Pyorrhoea  Pockets 21 

Figs.  14  and  15.     Abscesses  from  Temporary  Teeth 21 

Figs.  16, 17, 18  and  19.     Abscesses  due  to  Decay  of  Permanent 

Teeth  21 

VI       Fig.  20.     Acute   Periodontitis 24 

Fig.  21.     Acute  Abscess 24 

Fig.  22.     Subperiosteal  Parulis 24 

Fig.  23.     Subgingival    Parulis 24 

VII       Figs.  24,  25,  26,  27,  28,  29,  30  and  31.     Sinus  Formations 25 

VIII       Fig.  32.     Skull  showing  Bone  Destruction  due  to  Abscesses 26 

IX      Fig.  33.     Ostitis,  caused  by  a  tooth 27 

Fig.  34.     Osteomyelitis  of  Mandible 27 

X      Figs.  35  and  36.     Photographs    of    Teeth   showing   Exostosis    of 

Eoot     28 

Fig.  37.     Molar  with  Scar  Bone 28 

XI       Fig.  38.     Central  Incisor  with  Acute  Abscess 29 

Fig.  39.     Photograph  of  Subgingival  Parulis 29 

XII      Fig.  40.     Lateral  Granuloma  34 

Fig.  41.     Apical    Granuloma 34 

Fig.  42.     Interradial   Granuloma    34 

XIII       Figs.  43,  44  and  45.     Granulomata  caused  by  Decay  of  Tooth. .  35 
Figs.  46,  47  and  48.     Granulomata  caused  by  Incomplete  Pulp 

Extirpation     35 

Figs.  49  and  50.     Granulomata  due  to  Broken  Instruments 35 

XIV      Figs.  51,  52,  53,  54,  55   and  56.     Granulomata  caused  by  In- 
efficient Eoot  Canal  Fillings 38 

Figs.  57,  58  and  59.     Granulomata  from  Decay  under  Filling.  .  38 

Figs.  60,  61  and  62.     Granulomata  on  Crowned  Teeth 38 


202 


INDEX  OF  ILLUSTRATION'S 


PLATE 

XV 

XVI 
XVII 


XVIII 


XIX 


XX 


XXI 


XXII 

XXHI 

XXIV 

XXV 

XXVI 

XXVII 

xxvni 

XXIX 


TACING 
PAGE 

Fig.  63.     Skull  showing  Bony  Destruction  Caused  by  an  Apieal 

Granuloma    39 

Fig.  64.     Skull  showing  Bony  Destruction  due  to  a  Granuloma. .     40 
Figs.  65,  66,  67,  68,  69  and  70.     Badiographs  showing  Exostosis 

of  Boots 41 

Figs.  71,  72  and  73.     Badiographs  showing  Teeth  with  Necrosed 

Apices   41 

Fig.  74  and  75.     Badiographs    of    Teeth    showing    large    Oste- 

omyelitic   Areas    41 

Fig.  76  and  77.     Badiographs  of  Teeth  showing  Small  Areas  in- 
dicating   Periodontitis 44 

Fig.  79,  80  and  81.     Badiographs  of  Teeth  showing  Large  Areas 

indicating  Granulomata 44 

Fig.  82  and  83.     Badiographs  of  Teeth  with  Subacute  Abscesses    44 
Fig.  84, 85  and  86.     Badiographs  showing  Pus  Pockets  caused 

by  Mechanical  Injury 45 

Fig.  87, 88, 89    and   90.     Badiographs    of   Teeth   showing   Dark 

Areas  at  the  Alveolar  Border 45 

Fig.  91.     Badiograph   showing   Apical   Abscess   caused   by   Pus 

Poeket;   Tooth  Vital 45 

Figs.  92,  93,  94  and  95.     Badiographs  showing  Abscesses  caused 

by  Impacted  Wisdom  Tooth 48 

Fig.  96,  97  and  98.     Badiographs  of  Abscesses  caused  by  TTn- 

unerupted    Molars 48 

Fig.  99.     Badiograph  showing  Impacted  Second  and  Third  Molar     49 
Pig.  100.     Badiograph    showing   Broken    Off    Impacted    Second 

Molar    49 

Figs.  101  and  102.     Badiographs   showing   Impacted    Temporary- 
Molars     49 

Figs.  103, 104, 105, 106,  107  and  108.     Other  Impacted  Teeth. . .     49 
Fig.  109.     Badiographic    Plate    showing    an    Impacted    Upper 

Third  Molar  on  Posterior  Wall  of  Antrum 50 

Fig.  110.     Badiographic  Plate  showing  Unerupted  Lower  Third 

Molar  at  the  Angle  of  Jaw 51 

Fig.  111.     Simple  Abscess  of  Tongue 52 

Fig.  112.     Tubercular  Abscess  of  Tongue 52 

Fig.  113.     Swelling  under  Tongue  on  Left  Side 56 

Fig.  114.     Badiograph  showing  Salivary  Calculus 56 

Fig.  115.     Badiograph  of  Granuloma 58 

Fig.  116.     Smear  of  Bacteria  Contained  in  above  Granuloma. .     58 

Fig.  117.     Tooth  with  Large  Granuloma 68 

Fig.  118.     Microphotograph  of  Section  of  Above  showing  Actin- 
omycoses Colonies   68 

Fig.  119.     Microphotograph  of  Section  through  Granuloma  show- 
ing Actinomycoces  Colonies 70 

Fig.  120.     Microphotograph  of  Chronic  Myocarditis  produced  in 

Babbit    72 

Fig.  121.     Microphotograph  of  Acute  Myocarditis  produced  in 

Babbit     72 


INDEX  OF  ILLUSTRATIONS 


203 


PLATE 

XXX 

Fig. 

Fig. 

XXXI 

Fig. 

XXXII 

Fig. 

Fig. 

Fig. 

Fig. 

XXXIII 

Fig. 

Fig. 

xxxrv 

Fig. 

Fig. 

XXXV 

Fig. 

Fig. 

Fig. 

XXXVI 

Fig. 

Fig. 

XXXVII 

Fig. 

XXXVIII 

Fig. 

Fig. 

XXXIX 

Fig. 

XL 

Fig. 

Fig. 

Fig. 

XLI 

Figs. 

XLII 

Fig. 

Fig. 

XLIII 

Fig. 

XLIV 

Fig. 

XLV 

Fig. 

Fig. 

XLVI 

Figs, 

XLVII 

Fig. 

Fig. 

XLVIII 

Fig. 

XLIX 

Fig. 

L 

Fig. 

Fig. 

FACING 
PAGI 

122.  Microphotograph  showing  Infiltration  of  Leucocytes 
and  Lymphocytes  in  Kidney  of  Eabbit 74 

123.  Microphotograph  showing  Polymorphonuclear  Abscess 
in  Medulla  of  Kidney  of  Eabbit 74 

124.  Microphotograph  of  Epitheliated  Granuloma 76 

125.  Microphotograph  of  Simple  Granuloma 78 

126.  Microphotograph  of  Simple  Granuloma  showing  dis- 
tinct Capsule  78 

127.  Microphotograph     of     Simple     Granuloma     showing 
Active  Pus  formation 78 

128.  Microphotograph  of  Granuloma  with  Sinus 78 

129.  Lithograph    showing     Construction     of    Capsule    of 
Granuloma    (Fig.   127) 80 

130.  Lithograph     showing     Construction     of     Granuloma 
(Fig.  124)    80 

131.  Lithograph  of  Inner  Part  of  Granuloma  of  Fig.  124  80 

132.  Lithograph  of  Inner  Part  of  Granuloma  of  Fig.  128  80 

133.  Radiograph  showing  Granuloma  in  Lateral  Incisor. .  81 

134.  Photograph  of  Excised  Granuloma 81 

135.  Microphotograph  of  same  Granuloma 81 

136.  Lithograph    of    High-power   Drawing   of    Granuloma 
(Fig.    135)     82 

137.  Lithograph  of  High-power  Drawing  of  another  part  82 

138.  Antrum  exposed  to  show  Abscess 90 

139.  Radiograph  of  Case  1 91 

140.  Radiographic  Plate  of  Case  1 91 

141.  Cross  Section  through  Eye 94 

142.  Acute  Catarrhal  Conjunctivitis 95 

143.  Simple  Ulcer  of  Cornea 95 

144.  Normal  Eye,  and  Iritis 95 

.  145,  146,  147  and  148.     Radiographs  of  Case  VI 98 

149.  Radiograph  of  Case  VII 99 

150.  Radiograph  of  Case  VIII 99 

151.  Position  of  Lymph  Glands  beneath  Lower  Jaw 100 

152.  Schematic  Drawing  showing  Teeth  Drained  by  Lymph 
Glands 101 

153.  Radiograph  Case  IX 104 

154.  Radiograph  Case  X 104 

.  155  and  155a.     Radiographs  of  Case  XI 105 

156.    Radiograph  of  Case  XVII 122 

157  and  158.     Radiograph  of  Case  XVII 122 

159  and  159a.     Radiograph  of  Case  XX 123 

160.  Radiographic  Plate  of  Case  XXI 130 

161.  Radiograph  of  Case  XXII 131 

162.  Radiographic  Plate  of  Case  XXII 131 


204 


INDEX  OF  ILLUSTRATIONS 


FACING 
PLATE  PAGE 

LI       Figs.  163,  164  and  165.     Eadiographs  of  Case  XXVII 136 

LII      Fig.  166.     Normal    Hand 137 

Fig.  167.     Hypertrophic  Arthritis     137 

LIII       Fig.  168.     Gouty  Arthritis    138 

LIV       Fig.  169.     Infectious   Arthritis    139 

Fig.  170.     Atrophic   Arthritis    139 

LV       Fig.  171.     Eadiographic  Plate  of  Case  XXVIII 142 

LVI       Fig.  172.     Eadiograph  of  Case  XXVIII 143 

Fig.  173.     Eadiographic  Plate  of  Case  XXIX 143 

LVII       Figs.  174,  175,  176,  177,  178  and  179.     Eadiographs  showing  a 

Large  Amount  of  Bridgework  and  Many  Abscesses. .  144 

LVIII       Figs.  180,  181,  182,  183,  184  and  185.     Eadiographs  of  a  Neg- 
lected  Mouth 145 

LIX       Figs.  186  and  187.     Eadiographs  revealing  Deep  Cavities  causing 

Obscure    Pain 146 

Fig.  188.     Eadiograph  shows  a  large  amount  of  trouble 146 

Figs.    189,   190,   191,   192   and   193.     Eadiographs   showing  the 

Value  of  X-Eays  before  undertaking  Eoot  Canal  Work  146 

LX       Fig.  194.     Eadiographic  Examination  of  a  Mouth 147 

Fig.  195.     Chart  Indicating  Granulomata  and  Eoot  Canal  Fil- 
lings of  the  above  case 147 

LXI       Fig.  196.     Eeport  Chart  as  used  by  Dr.  Potter 148 

LXII      Figs.  197, 198, 199  and  200.     Steps  in  Apiectomy    162 

LXIII       Figs.  201,  202,  203  and  204.     Steps  in  Apiectomy    162 

LXIV       Figs.  205,  206,  207  and  208.     Steps  in  Apiectomy    162 

LXV       Figs.  209,  210  and  211.     Eadiographs  of  Three  Cases  not  favor- 
able for  Apiectomy 164 

LXVI       Figs.  212  to  220.     Eadiographs  showing  the  Treatment  of  Five 

Devitalized  Teeth  165 

LXVII       Figs.  221,  222,  223,  224,  225,  226  and  227.     Eoot  Canal  Treat- 
ment and  Apiectomy  on  a  Lateral  Incisor 166 

Figs.  228,  229,  230  and  231.     Eoot  Canal  Treatment  and  Apiec- 
tomy on  Another  Lateral  Incisor 166 

Figs.  232,  233,   234  and  235.     Process  of  Apiectomy  on  Two 

Teeth  shown  by  Eadiographs 166 

LXVIII       Figs.  236,  237  and  238.     Eadiographs  showing  Apiectomy  on  a 

First   Bicuspid 167 

Figs.  239,  240,  241  and  242.     Eadiographs  of  Apiectomy  on  a 

Cuspid    167 

LXIX       Figs.  243,  244,  245  and  246.     Apiectomy  on  a  Cuspid  which  is 

the  Abutment  of  a  Bridge 168 

Figs.  247  and  248.     Apiectomy  on  a  Lateral  Incisor 168 

Figs.  249  and  250.     Apiectomy  on  a  Central  Incisor 168 

Figs.  251,  252  and  253.     Apiectomy  on  a  Central  and  Lateral  In- 
cisor        168 

LXX      Figs.  254  and  255.     Apiectomy  on  a  Lower  Incisor 169 

Fig.  256.     Apiectomy  on  Two  Lower  Incisors 169 


INDEX  OF  ILLUSTRATIONS 


205 


FACING 
PLATE  PAGE 

LXX      Pigs.  257  and  258.     Apieetomy  on  a  Lower  Incisor  with  Broken 

Eoot  Instrument     169 

Figs.  259  and  260.     Apieetomy  on  a  Lower  Bicuspid 169 

LXXI  Figs.  261,  262  and  263.  Kadiographs  showing  Healing  of  Bone.  170 
Figs.  264,  265  and  266.  Kadiographs  showing  Healing  of  Bone.  170 
Figs.  267,  268  and  269.     Eadiographs  showing  Healing  of  Bone.   170 

LXXII       Fig.  270.     A  Selection  of  Curettes 171 

LXXIII       Figs.  271  and  272.     Excision  of  Tip  of  Tongue 172 

LXXIV       Fig.  273.     Microphotograph  showing  Multiple  Foramina 180 

LXXV       Fig.  274.     Microphotograph  showing  a  Boot  Canal  Filling 182 

LXXVI      Figs.  275,  276  and  277.     Eadiographs    showing    the    Process    of 

Eoot  Canal  Treatment 184 

Figs.  278, 279  and  280.     Eadiographs    showing    the    Process    of 

Eoot  Canal  Treatment 184 

Figs.  281  and  282.     Eadiograph  showing  Poor  and  Good  Eoot 

Canal   Filling 184 

LXXVII       Fig.  283.     Eoot  Treatment  through  Small  and  Large  Cavity 185 

Figs.  284  and  285.     Specimen  of  Bent  Eoots 185 

LXXVIII       Figs.  286,  287,  288  and  289.     Models  of  a  Patient's  Mouth  (Age 
35)    who  had  the  Four   Six-year   Molars   Extracted 

at  Age  of  Thirteen  Years 189 

LXXIX      Figs.  290  and  291.     Models  of  the  Mouth  of  a  Boy  Aged  Thirteen  190 
Figs.  292  and  293.     Models  of  same  mouth  Three  Years  Later, 

All  Six-year  Molars  having  been  Extracted 190 


INDEX 


Abscesses 


PAGE 

acute   alveolar 24 

acute  alveolar,  histological 

pathology   of 77 

acute,  methods  of  collect- 
ing bacterial  specimens.  59 

alveolar,   chronic 27 

bacterial  specimens  of  59 

clinical  signs 30 

general  symptoms....  30 

histological   pathology  78 

local   symptoms 30 

radiographic  examina- 
tion      31 

subacute    28 

alveolar,    due    to    difficult 
eruption,  impaction,  and 

unerupted  teeth 47 

clinical  signs 50 

course  of  disease 47 

diagnosis     49 

etiology   47 

general  symptoms ....  50 

local  symptoms 49 

radiographic  examina- 
tion      50 

alveolar,  due  to  diseases  of 

dental  pulp 18 

pathological     develop- 
ment of 18 

alveolar,  due  to  disease  of 

the  gum 45 

clinical  signs 47 

course  of  disease 46 

diagnosis 47 

etiology  45 

general  symptoms ....  47 

local   symptoms 47 

radiographic  examina- 
tion      47 

treatment    of 169 

of     salivary     glands     and 

ducts    54 

clinical  course 56 

clinical  signs 57 

diagnosis 56 

etiology 55 

local   symptoms 56 

radiographic  examina- 
tion      57 


PAGE 

Abscesses    of    salivary    glands    and 
ducts. — Continued. 

treatment    173 

excision    of    glands  175 
operation  from  floor 

of  mouth 174 

of  tongue 51 

treatment  of 171 

varieties    51 

phlegmonous 52 

clinical  signs 53 

diagnosis 53 

etiology  52 

general  symptoms. .  53 

simple    51 

clinical  course 52 

clinical  signs 52 

diagnosis 52 

etiology  52 

local  symptoms ....  52 

tubercular 53 

clinical  course 54 

clinical  signs 54 

diagnosis     54 

etiology  53 

general  symptoms. .  54 

local   symptoms ....  54 

oral,  history  and  varieties  15 

bacteriology   of 58 

histological   pathology 

of   77 

review  of  bacteriologi- 
cal study  of 61 

Absorption,  channels  of 12 

Actinomycosis,      investigations       of 

Thoma  70 

Action  of  bacterial  ferments 8 

Affections  of  the  nervous  system ....  128 

Alimentary  canal,  diseases  of 109 

haematogenous  in- 
fection of 110 

Alveolatomy  162 

Anaemia   121 

pernicious   122 

primary  and  secondary....  121 

septic 122 

Case  XIX 122 

etiology  122 

symptoms    122 


INDEX 


207 


PAGE 

Anaesthesia  for  pulp  extirpation. . . .   181 

local    164 

Angina    53 

Animal   inoculation 61 

Antiseptic   medication 182 

Antitoxin    6 

Apiectomy    164 

failures  and  dangers 166 

healing  of  wound 166 

operation    165 

preparing  the  patient 164 

Appendicitis  113 

Application  of  counter-irritants  for 

acute  abscesses 152 

Arkovy,  bacterial  table 62 

Arthritis    135 

Asepsis    and    sterilization    in    root 

canal    185 

acute  infections 135 

Case  XXVII 136 

etiology  136 

atrophic 138 

Cases  XXVII,  XXIX  140,142 

etiology  138 

treatment    139 

chronic  infectious 137 

hypertrophic 137 

etiology  137 

Aural  disturbances 100 

Author  'a  remark 75 

Autoinoculation,  surgical 176 

B 

Bacteria,  invasion  of,  causing  prolif- 
erating periodontitis  ....  38 
aerobic  and  anaerobic,  culti- 
vation of 60 

Bacteremia   11 

Bacterial  ferments 2 

action  of 8 

Immunity    5 

investigations : 

Arkovy    62 

Author 's  remark 75 

Gilmer  70 

Goadby    62 

Hartzel  and  Henriei 71 

Mayerhof  er 65 

Miller    61 

Monier 63 

Partsch   63 

Schreier 61 

Steinharter   75 

Thoma 70 

Vincent   65 

metabolism,  by-products  of  9 
specimens,    method    of    col- 
lecting     60 


PAGE 

Bacteriological  study,  importance  of  59 

review  of 61 

Bacteriology  of  Oral  Abseesses 58 

Biological  laws  of  Vaughan 5 

Black's  1,  2,  3 152 

Blood,  changes  of,  during  infection. .  11 

diseases  of 115 

Body  cell,  the 3 

ferments  of 3 

sensitization  of 9 

Buckley 's  modified  phenol 151 

C 

Calculi,  salivary  in  glands  and  ducts    55 

Cards  for  examination 146 

Case  charts,  Potter 149 

Cathartics  in  acute  abseesses 145 

Changes  in  blood  from  infection. ...     10 
Change    in    oxygen   tension    causing 

acute  periodontitis 26 

Channels  of  absorption 12 

Chart,  radiographic 149 

Cholesterin,    degeneration   in   granu- 
loma       83 

Chorea  132 

Case  XXIV 133 

etiology  132 

Choroiditis    97 

etiology 97 

symptoms    97 

Chronic  alveolar  abscess 33 

clinical  signs 34 

general  symptoms 33 

local   symptoms 33 

radiographic  examination    34 

Chronic  conditions,  treatment  of 157 

Classification  of  oral  abscesses 16 

Clinical  picture  of  infection 9 

Colitis    113 

Collection  of  bacterial  specimens . .  59,  60 

Complications    84 

of  acute  periodontitis.     26 

secondary    84 

systemic  treatment  of  178 

Conjunctivitis 95 

infectious 95 

etiology    95 

symptoms 95 

Counter-irritants,  application  of  for 

acute  abscess    152 

Cover  glass  preparations 60 

Cultivation  of  aerobic  and  anaerobic 

bacteria 60 

Curettage  and  extraction  in  abscessed 

conditions   167 

Cyelitis    97 

Cysts    41 

Cysts  in  granulomata 83 


208 


INDEX 


D 

PAGE 

Decay  of  deciduous    teeth    causing 

acute  periodontitis 21 

first   molar 189 

permanent     teeth    causing 

acute  periodontitis 22 

the  teeth  causing  prolifer- 
ating  periodontitis 36 

Decrease  of  resistance 4 

Defence  of  the  body,  protective 4 

Devitalized  teeth,  prevention  of 186 

Disease,  secondary,  prevention  of . . .   179 
Diseases  of  soft  tissues,  examination 

of    147 

the  alimentary  canal ....   109 

blood    115 

heart    123 

joints     135 

teeth    147 

Diagnosis  of  condition  of  devitalized 

teeth    148 

abscesses  caused  by  ab- 
scesses of  tongue,  sal- 
ivary    glands     and 

ducts 51,  56 

abscess  of  the  tongue. .     52 
acute   periodontitis ....      29 
alveolar         abscesses 
caused  by  diseases  of 

the  dental  pulp 18 

alveolar  abscesses  due 
to  other  causes  than 
diseases  of  the  dental 

pulp   45 

phlegmonous  abscess  of 

the   tongue 53 

proliferating  periodon- 
titis          29 

tubercular    abscess     of 

the   tongue 54 

unerupted  and  impact- 
ed teeth 49 

Ducts,   pathological   development   of 

salivary  abscesses  from ....     51 

abscesses  from 54 

Duodenum 

ulcer  (see  Ulcer) 113 

E 

Ear  (see  Aural  disturbances) 100 

Efficiency  of  treatment  of  granulo- 

mata,  original  investigations 158 

Electrolytic  treatment  for  abscesses.  161 

for  root  canal  work  ....  184 

Endocarditis 125 

acute  and  chronic 125 

Case  XX 127 

treatment    125 


PAGE 

Enteritis,    septic 112 

etiology  112 

Case  XIV 113 

symptoms    112 

Europhorm  paste 155 

Exacerbation    167 

Examination  cards 146 

Examination  of  oral  cavity 144 

by   dentist 146 

physician     145 

Examination  of  soft  tissue  of  mouth  145 

the  teeth 146 

physical     146 

Excision  of  salivary  glands 175 

small      tubercular      ab- 
scesses of  tongue  ....   172 

tongue  V-shaped 172 

Exostosis  of  root 28 

Extirpation    of    impacted    and    un- 
erupted  teeth 170 

preanaesthetic  medication  after 

treatment    171 

Extirpation  of  teeth 168 

anaesthesia   168 

care  of  wound 169 

indication    168 

operation     168 

Extracellular  ferments 2 

toxins    3 

Extraction  and  curettage  of  abscessed 

condition 167 

of  badly  decayed  first  molars 

in  children 190 

teeth  in  acute  abscesses. . .   154 

F 

Ferments,  action  of  bacterial 8 

analytic 2,  3 

bacterial    2 

extracellular  2,  3 

intracellular    2,  3 

of  body  cell 3 

synthetic   2,  3 

Fever,  general  effects  of  local  infec- 
tion         10 

Fever  in  acute  abscesses 30 

acute  sinusitis 116 

alveolar  parulis 33 

pyaemia 117 

from  impacted  and  unerupted 

teeth    50 

rheumatic   in   acute   infectious 

arthritis    135 

Filling    teeth    with    infected    pulps 

causing  acute  periodontitis 30 

Focus  of  infection 13 

Focus,  removal  of 176 

Formaldehyde  contraindicated 182 


INDEX 


209 


G 

PAGE 

Galvanic  current  for  diagnosis. .  .30,  34 

Gilmer,  bacterial  investigation  of . . .  70 

Glands,  salivary  abscesses 51 

pathological  development  of  54 

Glaucoma    99 

etiology    99 

primary  and  secondary. ...  99 

symptoms 99 

Goadby,  bacterial  investigations  of . .  62 

Granuloma    39 

apical    36 

clinical  signs 43 

epitheliated    81 

general  signs 43 

histological   pathology...  79 

interradial    39 

local   symptoms 42 

lateral    37 

methods  of  collecting  bac- 
terial  specimen 60 

with   lumen 82 


Hartzel  and  Henrici,  bacterial  inves- 
tigations 
table     of     fer- 
mentation...    73 

Heart,  diseases  of 123 

High  frequency  current  for  diagnosis     30 
History    and    varieties    of    oral    ab- 
scesses        15 

Hyalin  degeneration  in  granuloma..     83 


I 

Idman,  bacteriological  investigation  66 

Immunity,  acquired 5 

bacterial    5 

natural    5 

toxin    5 

Impacted  teeth 48 

extirpation   of 170 

Incision  in  simple  abscess  of  tongue.  171 

Infection,  phenomena  of   1 

from  pus  pockets  causing 

acute  periodontitis 20 

Infections  10 

acute  and  chronic 10 

clinical    picture 9 

continuous    84 

from  adjacent  teeth  caus- 
ing acute  periodontitis. .  20 

general    11 

general  effects  of 10 


PAGE 

Infections,  haematogenous    85 

causing  proliferating 

periodontitis 39 

influence  of  quantity  on . . .  9 

local     10 

lymphatic    85 

predilection  of 13 

prevention  of  periapical  . .  180 

secondarily  transported...  11 

virulence    9 

Infection  through  alimentary  canal.  85 

Infective  virus,  the 1 

Injury  of  the  gum  causing  alveolar 

abscess    45 

Inoculation 10 

of  animals 61 

of  artificial  media 60 

Instrumentation  causing  acute  peri- 
odontitis      23 

Intracellular  ferments 2 

Investigation,  original,  of  the  efficien- 
cy of  treatment  of  granulomata. . .  158 
Involvement  of  neighboring  parts ...  86 
Iodine  for  root  canal  treatment. . . .  184 

Ionic   medication 161,  184 

Iridiohoroiditis 97 

Iridocyclitis    96 

etiology 97 

symptoms    97 

Iritis    97 

etiology 97 

symptoms    97 

J 

Joints,  diseases  of 135 

K 

Keratitis  suppuration 95 

etiology     95 

symptoms    95 


L 

Laxative  in  acute  abscess 156 

Lead  points  for  root  canal  fillings..  163 

Lymphadenitis,  cervical 104 

acute    104 

Case   X 106 

etiology  105 

symptoms 105 

treatment 105 

chronic 106 

etiology  106 

symptoms 106 

treatment 106 


210 


INDEX 


PAGE 

Lymphadenitis,    subacute 106 

Case   XI 106 

symptoms 106 

#  tubercular  106 

Case  XII 109 

etiology   107 

symptoms    107 

treatment    107 

Lymphangitis     103 

Case  IX 104 

etiology   103 

symptoms 103 

treatment 103 

Lymphatic  infection 102 

Lymph  glands,  enlarged 146 

location 102 

M 

Malaise   119 

treatment  of 119 

Manifestations   secondary 13 

Mastication  efficiency,  restoration  of  177 
Mayerhofer,    bacteriological    investi- 
gations    65 

table    66 

Medication,  antiseptic 182 

ionic    161 

for  root  canal  treat- 
ment      184 

Melancholia    133 

Case  XXVI 135 

Menier,  bacterial  investigation 63 

bacteriological  table 65 

Mental  depression 133 

Case   XXV 134 

Metabolism,  by-products  of  bacterial  8 

Metastasis 11 

Methods  of  animal  inoculation 61 

bacterial  study 60 

collecting  bacterial  speci- 
mens     59 

Middle  ear  inflammation 100 

Miller,  bacterial  investigation 62 

Molar,  early  decay  of  first 189 

Myocarditis    121 

N 

Natural   Immunity 5 

Necrosis    26 

of  root 29 

Nerve    communication   between    ear 

and  teeth 100 

communication    between    eye 

and  teeth 94 

reference  table 131 

Nervous  system,  affections  of 128 


TAGE 

Neuralgia,  trifacial 130 

Case  XXII 132 

Case  XXIII 132 

etiology   130 

symptoms 132 

Neuritis 128 

Case  XXI 129 

etiology 128 

general    129 

symptoms    129 

intraocular  optic 98 

etiology  98 

symptoms    98 

retrobulbar    optic 98 

Case  VI 98 

etiology   98 

symptoms 98 

o 

Occlusion,  sufficient 190 

Ophthalmic  disturbances 94 

Optic  neuritis 98 

Oral  abscesses,  treatment  of 150 

cavity,   examination   by   physi- 
cian      145 

examination  of 144 

Osteomyelitis,  acute 26 

chronic 41 

Ostitis    26 

Otalgia    101 

Case  VIII 101 

Otitis  media 100 

Case  VII 101 

Overdentistried  teeth 146 

P 

Pain  in  ear  (Otalgia) 101 

relief   of 156 

Papillitis 98 

Paresthesia 129 

Partsch,  bacterial  investigation 63 

Parulis,  alveolar 24 

clinical  signs 33 

differential  diagnosis 32 

general  symptoms 33 

histological   pathology 78 

local   symptoms 31 

radiographic  examination. .  33 

Parulis,  subgingival 25 

subperiosteal    24 

Pathological  development  of  absces- 
ses   of    tongue    and 

salivary   glands 51 

development  of  alveolar 
abscesses  caused  by 
diseases  of  the  den- 
tal pulp 18 


INDEX 


211 


PAGE 

Pathological  development  of  alveo- 
lar abscesses  due  to 
other  causes  than 
disease  of  the  dental 

pulp   45 

Pathology,    histological 77 

Peptic  ulcer 113 

Periapical  infection,  prevention  of..  180 

Pericarditis 124 

Periodontitis    19 

acute  and  its  sequels 19 

acute  interradial 19 

acute  lateral 19 

clinical  signs 29 

diagnosis 29 

histological  pathology 77 

apical 19 

complication 26 

course  of  disease 24 

definition    19 

etiology  20 

Periodontitis,  proliferating 

clinical    signs 42 

diagnosis 42 

general  symptoms 42 

local  symptoms 42 

radiographic  examination 42 

Periodontitis,   proliferating   and   se- 
quels      34 

course  of  disease 39 

definition 34 

etiology  45 

histological  pathology 79 

termination 41 

varieties    35 

Pharyngitis 92 

Case  III 92 

symptoms 92 

treatment 92 

Phenomena  of  infection,  the 1 

Physical  examination  of  oral  cavity.  145 

Poison,  protein    7 

Potter,  case  charts 149 

Prevention 178 

of  abscesses  by  early  treat- 
ment    188 

caries  by  prophylaxis. .  188 

devitalized  teeth 186 

devitalized  teeth  by 
treatment  of  hyper- 
emia   and    exposures 

of  the  pulp 187 

periapical    infection. . .  180 
secondary    diseases 

from  oral  abscesses.  179 

Process  of  infection,  the 6 

Proctitis    113 

Protective  defenses  of  the  body ....  4 


PAGE 

Protein  poison 7 

poison   caused  by   bacterial 

metabolism 8 

poisons   59 

sensitization    6 

Prognosis    before   root    canal   treat- 
ment        148 

Pulp,  death  of,  without  access  of  air, 
causing  proliferating  peri- 
odontitis       38 

extirpation  incomplete  caus- 
ing proliferating  periodon- 
titis       36 

Pulp  extirpation,  anaesthesia  for. . .  180 

Pus    pockets    causing    alveolar    ab- 
scesses         46 

Pyaemia    117 

etiology 117 

illustrative  Case  XVI 117 

symptoms 117 

treatment 117 

R 

Eadiographic  chart 149 

diagnosis    before    root 

canal   treatment  ....   181 
diagnosis  important  in 
secondary    infection .     84 

examination 148 

in  acute  maxillary 

sinusitis     87 

in    chronic    maxil- 
lary sinusitis...     88 
in  trismus  of  mus- 
cles  of   mastica- 
tion         93 

of    acute    alveolar 

abscesses   31 

of  alveolar  absces- 
ses caused  by 
diseases    of    the 

gum    47 

of  alveolar  parulis     33 
of   chronic   absces- 
ses         34 

of  granulomata. . .     43 
o  f       proliferating 

periodontitis  ...     42 
of  salivary  stones.     57 
of  subacute  attacks    44 
of    unerupted    and 
impacted  teeth. .     50 
Eadiotherapy  for  tubercular  lymph- 
adenitis      108 

Belief  of  pain 156 

Eemoval  of  the  cause  in  acute  and 
chronic  conditions 160 


212 


INDEX 


PAGE 

Eesistance 4 

decrease    of 4 

increase  of 5 

Resolution  of  aeute  periodontitis. ...     27 
of  proliferating  periodon- 
titis          41 

Eest  of  diseased  tooth 152 

Restoration  of  masticating  efficiency  177 

Retinitis    97 

etiology    97 

symptoms 98 

Review   of   bacteriological   study   of 

oral  abscesses 61 

Rheumatic  fever  (see  acute  arthritis)  135 

Root  exostosis    40,  28 

necrosis    40,  29 

Root  canal  cleaning  and  enlarging . . .  181 

filling 185 

drying    185 

radiographic  examination 

before  apiectomy 164 

treatment,     asepsis     and 

sterilization    185 

treatment    before    apiec- 
tomy    148 

S 

Sapremia 118 

Scar  bone 27 

Schreier,  bacterial  investigation ....     61 

bacteriological  table 62 

Scleritis 95 

etiology   95 

Case   V 96 

symptoms    95 

Sensitization :    protein 6 

of  body  cell 7 

Septicemia    116 

etiology  116 

symptoms    116 

treatment    116 

Sequestrum  27 

Sinus,  active    27 

closed    27 

to  face,  treatment  of 157 

Sinusitis  maxillary 86 

acute 86 

etiology   86 

clinical  signs -    87 

symptoms    86 

treatment    87 

chronic    88 

Case  1 90 

Case  II 90 

etiology   88 

clinical  signs 88 

symptoms    89 

treatment    89 


PAGE 

Sodium  potassium  treatment 181 

Steinharter,  bacterial  investigation.     75 
Sterilization  and  asepsis  in  root  canal 

treatment    185 

Summary  of  prevention  of  periapical 

infection   186 

Systemic   complications   treatment. .  175 
treatment    for    acute    ab- 
scesses     155 


T 

Table  of  nerve  reference 131 

Teeth,  devitalized,  examination  of . .   148 

examination    of 147 

extraction  and  extirpation. . .  168 
of    in    acute    ab- 
scesses     144 

overdentistried    146 

prevention  of  devitalized. . . .   186 
unerupted       and      impacted, 

differential  diagnosis 47 

Termination  of  acute  periodontitis . .     27 
Thermal  shocks  causing  acute  peri- 
odontitis         21 

Thoma,  bacteriological  investigations     70 

Thrombosis     117 

Tongue,  abscesses,  pathological  devel- 
opment        51 

abscesses,    treatment 171 

excision  of  small  tubercular 

lesions 172 

excision  of  V-shaped  part. .  172 
incision  in  simple  abscess..   172 

Toxemia    11 

Cases  XVII,  XVIII 120 

chronic     119 

etiology    118 

symptoms 119 

Toxins 

activity   6 

absorbed  from  granulomata . .     63 

definition 3 

extracellular   3 

intracellular    7 

Treatment  of  acute  and  subacute  con- 
ditions     150 

abscesses    due   to    diffi- 
cult eruption,  etc. . . .   169 
abscesses    due    to    dis- 
eases of  the  gum ....   169 
abscesses     of     salivary 

glands  and  ducts ....   173 
abscesses  on  tongue . . .   171 
caries    to    prevent    ab- 
scesses     188 

chronic  conditions  ....   157 


INDEX 


213 


PAGE 

Treatment  of  excision  of  glands ....  175 
hyperemia     and     expo- 
sures of  pulp  to  pre- 
vent devitalization  of 

pulp   187 

operation  from  floor  of 

mouth    174 

root   canals  in   chronic 
conditions     before 

apiectomy    163 

sinus  to  face 157 

systemic    complications  176 
systemic    complications 
for  acute  abscess. . . .   155 
with    antiseptics    applied 

to    root    canal 160 

Trismus,    etiology 93 

Case  IV 93 

diagnosis 93 

symptoms    93 

treatment    93 

Tubercular  lymphadenitis 106 

Tuberculosis  of  granuloma 63 


PAGE 

Trigeminal    neuralgia    (see    Neural- 
gia)       130 

True  value  of  a  tooth 189 

U 

Unerupted    teeth,    extirpation    (see 

Extirpation)   170 

Ulcers,  gastric  and  duodenal 113 

Case    XV 114 

etiology   113 

symptoms    113 

V 

Value  of  healthy  tooth 191 

Value,  true,  of  tooth 189 

Varieties  of  alveolar  abscesses  caused 

by  diseases  of  the  dental  pulp ....  18 
Varieties    and    history    of    oral    ab- 

sceses 15 

Vincent,     bacteriological     investiga- 
tions    65 

Virus,  the  infective 1 


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